it reminds you every day of where i used to be and where i am at now. i meeting of the health service system board. to order for may 20/5 2023. would you please stand and join me in saying the pledge of allegiance? watch allegiance to the flag. of the united states of america and to the republic for which it stands one nation under god,

indivisible with liberty and justice for all. before we begin our roll call for this meeting. i would like to introduce a new member. of our board. ah as you know, we have elected representatives and appointed representatives and one of the appointments is that we must have a member of the board of supervisors. and after much diligent searching, we found one and he's with us today. that's uh, district district six supervisor met dorsey. i just like to give brief bio on supervisor dorsey. he has a large long city government association, both with the san francisco police department as the communications director. and then serving for nearly 14 years and over 14 years in the city.

attorney's office, where he helped to support groundbreaking cases around marriage equality. educational access public health, tenants, rights and workers' protections. prior to joining the police department and 2020. supervisor dorsey led it. tobacco free kids communication strategy for the 2019 no on prop c campaign. as you may recall, that proposition was soundly defeated. ah by even though there was a multi million dollar campaign by the vaping giant, you'll labs super duck visor, dorsey is committed to providing passed to recovery for those struggling with addiction. supporting new housing at all levels to make growing demand and investing in public safety resources to assure that all people can feel safe in their communities. supervisor dorsey

we welcome you to this board. thank you so much. thank you. and with that police call the room. thank you. president. scott roll call, starting with president scott president, vice president hill present commissioner breslin. president commissioner canning president supervisor dorsey president commissioner follansbee present and commissioners bronski will be arriving super towards thank you. we have a quorum. the next item is general public comment agenda item number three is general public comment an opportunity for members of the public to speak on any matter within the board's jurisdiction that is not on the agenda, including requesting that a board the board plays a matter on a future agenda item. i'll be reading are full instructions. the health service board welcomes public comment during the public comment periods. there will be an opportunity for general public comment at the beginning of the meeting and an opportunity to comment on each agenda item on the agenda in person. public comment will be

first, then virtual public comment for anyone waiting in person. you're welcome to approach the podium now. each speaker will be allowed three minutes to comment in length unless the board president deems new public comment time limits during the meeting, all public comments made concerning the agenda item that has been presented a column ask questions of the policy body, but there's no obligation to answer or engage in dialogue with the collar. the health service board will hear up to 30 minutes of remote public comment total for each agenda item. remote public comment for people who have received an accommodation due to a disability will not count towards that 30 minute limit. remote public comments via web webex are that the members of the public attending the meeting via phone, um, calling in 4156550001. when prompted enter access code 2596583247. then press pound you'll be prompted to enter the weapon password. 1145, then press pound press star three to be added to the public comment. q and when you hear the prompt you have raised your hand to ask a question,

please wait to speak until the host calls on you. when the sister message says, your line has been muted, this is your time to speak. you will be muted and then i need and then muted when your time is expired for those watching the meeting on webex click on the raised hand icon to be placed in the queue to speak. a raised hand icon will appear next to your name. when you're in muted in the system. a request to unmute will appear on your screen. please select on mute to speak. when you hear me, say, welcome caller, you'll begin speaking. and when your time is expired, you'll be muted. please click on the raised hand icon to lower your hand at the end of speaking members of the public are encouraged to state their name clearly, although they may remain anonymous, i'll give an audible warning when you have 30 seconds remaining, and when you're three minutes have ended. i thank you for your call. you'll be placed back on mute and i'll meet the next color. we like to thank sf tv and media services for sharing this meeting with the public will begin with any person public comment. and no one has approached the podium, so we'll move to our remote public comment and i'll be checking to see if there's anyone in our remote public comic you at this

time. yeah. we have four colors on the line. zero colors have raised her hand at this time. i'll take a five second pause to see if anyone would like to raise their hand. no colors have raised their hand at this time. public comment is now closed. all right, thank you. we have a particular focus where the special meeting normally there are other board matters like financial reports. directors report of presidents report and then any specialized items that are on the agenda, along with rates and benefits. a few years ago, this board reconfigured its standing committees, and we decided that we would do rights and benefits as a committee of the whole rather than having a subcommittee, review it and then come to the board with another

review of the same material, so all of us are acting if you will, as a full board. on the rights and benefits item. the structure of this meeting is rates and benefits. and i would like to make a few opening comments to put a context around the action items that follow on this agenda. we have since january have been very diligently looking at a number of issues that have been impacting the results of the rates and benefits that you see before you today and i would just like to go back. to the presentation that was made. and our last word meeting in may. by our chief financial officer hussein and our lead actuary, mike clark. because that really begins the framework. the

influencer. if you will, for a lot of the outcomes that you're going to see in these action items they updated a report that they had provided to the board in february. and there were large drivers if you will. that influence the overall trend underlying trend. for what would later translate to us as health premium cost, uh, coming from our health plans. ah one of the issues that we've noticed over the past two years that we have had a very substantial underutilization of health plan services, and that's largely been been driven by the pandemic. and we knew that and we knew also that at some point we would be coming out of the pandemic and people would be then going back for various. services utilizing the health

plan resources that they had not used during the pandemic. we also knew that over this 2 to 3 year period of time, there has been a very large disruption in the labor forth. across the entire. labor force, particularly in health care services, and we have been impacted. as a system in our operations were about 50% staffed at this point in time, and i'd look at our chief operating officer to see if that's an approximation. and we've been diligently recruiting and pressing and so forth to get more folks in our operations to assist with members, quarries and so forth in our client service area. but health systems have also been impacted by those same forces. we also know that there have been increased. chronic conditions that have

been magnified by the pandemic. and that, too has had an impact on the utilization and the healthcare trend. there's been a substantial increase in mental health services and substance abuse services during this period of time. and then there has been cautious sting from the federal government. to the health plans in terms of how they are reimbursing. there's a whole coding reimbursement structure that's coming into place during this plan year. and we know that there has been some efforts to restrict how people want qualify for medicare at the state level. and so knowing these trends in these drivers were going to be there and having an update on this last month. whereas award and i looked around. i wasn't presiding at the last meeting for personal reasons. but i noticed that we had zero callers on the line. and no. one in the

chamber during the public comment period about this particular report and most of the other proceedings of the board last time. and that's been true for a couple of months and we have been trying to diligently ah show not only the external trends that we're going to impact this result that we're going to be seeing today but also taking a very good look at our own demographics and the change, uh of factors and utilization within our own claims system and analysis, and we had that report brought before us. we knew that aon was bringing to us and expectation that there was going to be a core. 7% rate if you will trend and that is almost double. what we saw the year before. the core medical inflationary trend

double in one year. and we've had indications of that, as we've worked with her plant health plan partners as our staff has gone into analysis and discussion negotiating around the contract renewal's. and we've also know that there are any number of other factors and pharmacy. and other types of services in the health plans that are also influencing these trend factors. so the question for us as a board and as a system is, how can we respond to these things? and we would like to be masters of the universe and say okay, we can control all of these factors. and we can ultimately influence and make the unilateral decisions about what the total cost of increase is going to be and what we're going to pay for it. well we're not masters of the universe. we

find that we've got some tools that we can exercise as aboard some. we have to make recommendations to other bodies here in the city, other administrative offices in the city. before we can actually act on them and incorporate them into our approach. with the health plan. they're probably three large buckets. that we. will be dealing with not only in this plan year but in the coming two years of our strategic plan around these issues. one of them is cost shifting. and as soon as we say that i feel a very mild earthquake under my seat because people in this room, though, that if we're saying cost shifting, is that problem to the employer or is it to the employees? well it may be that we have to look at both of those things. but we can't do that

unilaterally as a board. it requires actual contract negotiations. negotiations with the unions of the city. and so forth, and that has to be put through the department of human resources and then actual collective bargaining agreements have to be struck and so forth. and do you do that out of cycle? no you don't. but as we go forward, will we be trying to look at those issues? we don't know. there's also in the cost shifting area, things that we could be looking at in terms of ah income based contributions. uh that you people learning certain amounts of money would pay out slightly higher premium than those paying that are earning less. there are any number of organizations and i'm familiar with it do base their premiums on the gross earnings of employees. but if we were to

do something like that, that again, it's not a unilateral decision by the sport. it has to go through a whole process. we could talk about increasing the benefit waiting period before you become eligible for benefits . a change like that would require the same type of structured ah, discussions, negotiations and so forth. so just to look at this from a cost shifting standpoint is not a unilateral decision by the sport . it would be something that would have to look at proposed and then have it fit in with a larger strategies of the city as an employer. another broad areas to take a look at the delivery system and the various plans that we offer. and that strikes at the issue of planned design. you just can't go in one moment

to the health plan and say, hey, we want to change or health plan design and therefore we want you to give us a quote on this new plan design. in one necessary season. it will take some effort on the plans part to come up with a response to the design options that were ought more suggesting they have to price them out. we have to look at them to see if they fit with what we're trying to do, and it's a back and forth, but it's not something that can be immediately implemented. when we hear that we're going to be, uh , possibly faced with large premium increases. there's also the issue of pharmacy management. and the issue of pharmacy management is a very complex one. we don't control what ah, the pharmacy benefit managers do but. we tried to look at the various incremental systems of rebates and so forth.

but again. it's a matter of costs that are being driven by other forces outside of our control. the last big area that we can begin to look at is we could also under plan offerings eliminate certain benefits. but when you start to do that you then go into the competitive recruitment market because the benefits that we might be eliminating maybe the very ones that are attracting employees to go with another employer. so again, our options are limited. lastly there's a whole area of administrative and operational changes to simplify those activities that their in house or through our partner carriers. one of the big levers in that area is to go out and do competitive bidding on the health plans. that is a massive

undertaking, and it takes at least a year to get the rfp to go, uh, into the marketplace and so forth, so it wouldn't have any immediate impact on any current plan here, but you'd be looking at a new plan year beyond that, so we were to go out and competitively bid. this year. had we done that? it would be something that could impact 2024. so if we're to undertake that, in 2020, for it won't be until 2025 before any competitive bidding changes could be made. so uh, the other side of that is that we might say okay, let's uh buckle up and begin to do our own thing internally. beef up our own healthcare system. ah resources to maybe directly contract with health plans and directly contract with others, maybe

create a i collaborative to bid with partner companies or organizations with health plans , or maybe move to a line with calpers in some way, so we create a larger purchasing block in the marketplace. any of that type of administrative or operational change again is something that will take either time to consider. both the pros and cons as well as to begin to implement that. so we're left with very, very few. outcomes. other than trying to educate ourselves on where we are today . how we got here. and to begin to publicly share and educate as we try to do over these past several months in these meetings ah to the membership as well. so

the results that we're looking at today are not something that sort of jumped full grown from the browse zeus. it just sort of like came out of nowhere. we've had months of effort of analysis. discussion. negotiation and here we are today. and we hope that as we go through public comment that that background that i provided will help to frame the discussion. uh we are on a timetable. ultimately these rates have to go before the board of supervisors. we had to provide a preliminary estimation of costs. we knew it was going to be higher. and we know that next year just like rust. premiums will probably go up again. it's just like rust. it's always with you. the question is how much and we will try diligently as a board. and through our staff and

actuary and working with our health plans to try to come out of that process with something that is in a more agreeable results, and we might see today but any of these larger changes will indeed take time. and i just wanted to put that out there as part of the opening comments as we consider these particular action items during the course of this meeting. so i thank you for your indulgence and patients for allowing me to speak. at this point, we will move to item number four. thank you. president scott agenda item number four is the presentation on the 2023 rates and benefits calendar for the plan year. 2024 this is a discussion item and will be presented by executive director abby yet.

calendar for us, hmm. okay. thank you. yes the reason benefit calendar obviously was adjusted for today's meeting. and will also, um uh, we have put a temporary hold on a should we need a second meeting in june following the medicare presentations on june 8th the they were at the regular meeting, and then we'll have a temporary hold on june 12th. um that will get us in just in the nick of time into to be able to introduce the legislation at the board of supervisors on the 16th of june. are there any questions from the board about the rates and benefits calendar? if not, we will open it up to public comment. thank you, president scott. public comment is now open instructions are being displayed on the screen for

those watching and sf gov t v in webex in person. public comment will be first and then remote public comment for those colors on the line. press star three to be added to the public comment queue for those watching the meeting on webex. click on the raised hand. i can't be placed in the public comic you to speak, we'll begin with any in person public comment. and no one has approached the podium, so we'll move to our remote public comment. so we have four colors on the phone line. zero colors have specifically entered the public comment. q at this time, i'll indicate when there are no more colors in the queue and you'll hear any brief silence as we transition between colors. as a reminder to colors press star three to be added to the public comment. q. no one has raised their hand for the public comment. q. public comment is now closed. all right. thank you. we'll now move

to item number five. agenda item number five health plans 2024 rate summary active employee in early retiree health plans. this is the discussion item and will be presented by mike clark, with am. mhm. mike clark and uh, especially nice to meet you, supervisor dorsey. um i'm here to lead a discussion. as an overview to the three subsequent presentations will make today. asking for approval of recommendations for rating for most of the active employee and early retiree health plans for 2024. knowing that one of those plans for 2024 rates was approved at the last board meeting. the health net cannot be care plan. so on the first

page just summarizing what you'll see today presented for the recommended recommendation for rate changes for each of the health plans. we're gonna health net canopy care was approved last meeting. for the blue shield access plus plan, and it's corollary for the mixed medicare. families with unitedhealthcare suggesting a 14.4% increase. for the blue shield trio plan with this associated doctors epo plan for the mixed medicare families 2.9% increase for kaiser, presenting two different versions of rate cards for your review today. 12.5% increase if the same design is maintained for 2024. as well as the recommended approach to match the major blue shield and health. net h m o playing design that would be a ton 0.8% rate increase. and then

for the non medicare p p o a recommended increase of 1.7. so just a little background details starting on page three for the blue shield hmos again, 14.4% for access, plus 2.9% for trio. there was a substantial difference in the plan experience for each of these programs between access, plus and trio in 2022. which we reviewed with you and the march 23rd board meeting. there was as a result, a increase in the rate stabilization adjustment that also impacts rates transitioning from a by down obvious surplus in 2023 rating. to a buy up via deficit for 2024 rating. but as we reviewed with you and gained the approval in april, there is a benefit in the rating for this

plan from the one time center legal settlement, and so that is an added by down in 2024 rates, so we'll review that in the next presentation. for kaiser 12.5% increase for the same plan design or 10.8% increase if the plan design were to alter to match major features with the blue shield and health bed. humo plans this compares with 3.9% rate increase that occurred into the 2023 planned near the current plan here. the increase mostly reflects escalated cost trend factors that president scott as you alluded to ah, chief financial officer hussein and i presented at the last board meeting on may 11th, including labor shortages, inflation supply chain disruptions. increasing demand for care, increasing prescription drug costs and provider challenges. so if you look at that status quo 12.5% increase roughly 4% is based on

plant experience, which we reviewed with you and the april board meeting and then about 8.5% due to these expenses, escalation factors. for the non medicare ppl, um as we reviewed with you in the april meeting the experience from 2021 to 2022 largely tracked with are expected 7% trend. but there is a larger benefit and the non medicare p p o reading from the southern legal settlement, and that's what brings the recommended rate. for the non medicare p p. 021.7. just to give context for the distribution of us a bit. process membership. from the 2023 demographics report. you can see the head count for both active employees and early retirees by each of these plans. you know for active employees. kaiser is the dominant plan

about 62% of total enrollment. followed by the blue shield access plus plan at around 2020 , or 2022% of blue shield trio about 11% and then smaller percentages for the other plans. for early retirees, almost half are enrolled in the kaiser plan with a gun access plus in trio, um, having higher enrollments, but on the non medicare p p o side, you do see a much higher percentage of early retirees, and that plan, mostly driven by individuals who live outside the bay area. whereas retirees this is their only option made available. and that's the choice not available. designation for their pricing. pages six and seven just contain the high level overview of projected 2024 monthly rates. um for all plans

except kaiser pages, six and seven, looked the same. um we're not making design trained recommendations on those plans today. for kaiser. page six contains what rates would look like for the status quo plan design if there was not planned design train for 2024. impedes seven includes what rates and contributions and member contributions would look like. if there were planned design changes adopted as recommended today. and then the final page of this report just includes the 2023 plan, their rates and poor contributions and member contributions just for comparative reference. all right. are there any questions on this presentation from the board? commissioner followed. thank you very much. i think this is a really useful overview and i think as we go through the individual items will understand

, you know, maybe better, but i think a groups want to remind myself and everyone that this is the one year renewal cycle. we're not yet looking at. we don't have guarantees for 2025 or 2026, and just point out that the impact on the of the one time sutter legal settlement, which is a one time we won't see this again, um, from this part of money had a rather tremendous impact on the non medicare p p o plan. um, and there are a large number of early retirees in that plan, and so they serve benefit this year from that, but um, i think we will look at 2025, and we can't come up with some mechanisms to address the increasing cost of health care across the board. some of these other groups that maybe you know god got away this year will be important to recognize the stress and 2025 and i was like a pointed out and i think that's

really adequately and brilliantly summarizes this. this is just a harbinger of things to come. now thank you for your commentary. just one clarification. there may be additional cetera. legal settlement dollars. um, that applied for 2025 rating. you know, depending on what store comes in, it will not be projected to be nearly the amount that has come in already that was approved at the april board meeting. or are there other comments concerns questions issues from the board. at this point. thank you, mike. and you'll be back. we know that so we'll take public comment at this time. thank you, president scott. public comment is now open instructions are being displayed on the screen for those watching on sfp of tv and webex in person. public comment will be first and then remote public comment for those colors on the line. press star three to be added to the public comment

queue for those watching the meeting on web webex click on the raised hand. i can't be placed in the public comment. q to speak, we'll begin with any in person public comment. and no one has approached the podium, so we'll move to our remote public comment. i look to see if there are any colors in the public comment. q at this time. we have four colors in the queue . at this time, zero callers have raised their hands to speak a reminder to all colors. press star three to be added to the public comment. q i'll give five more seconds and then we'll close public comments. zero colors have raised their hand at this time. public comment is now closed. thank you. will now move to item number five. president scott. i believe agenda item number six. i'm sorry. six okay

. agenda item number six is review and approve the non medicare blue shield of california flex funded hamo and united healthcare. self funded gpo medical rx plans for 2022 rates and contributions. this is an action item and will be presented by mike clark, with am mike clark and presenting on the blue shield of california hmo and the corollary unitedhealthcare ppo plans the ladder applying for mixed non medicare mixed medicare family members where one or more family member is enrolled in the united healthcare medicare advantage plan. so i'll do a brief rate setting methodology. profits lead through a renewal summary of what's creating the recommended increases for each of these plans. presentation of the rate cards proposed for 2024 for the plans. in closing with recommended nation for health service board action. one reminder. before i began. we specifically order these

presentations and these action items. how we have, for instance , doing this h blue shield. hmm. presentation first before the non medicare ppl presentation because there are elements of the non medicare plan pricing that are dependent on this. so for instance, the provisions and the mou that the highest cost plan as an employer contribution geared to the level of the second highest cost plan means access plus would need to be approved before we can improve rate cards. for the non medicare p p o and then also the choice not available. the more preferential ah member contribution scenario for the non medicare p p o plan is tied to access plus. contributions as well. and so i just wanted to remind everybody. that's why we order these presentations the

way they do because of some dependencies on the non medicare p p o that rely on how the great cards are set for the access plus plan. thank you for that clarification, mike. hmm hmm. so just real quick. there are three types of funding methods, self funded, flux, funded and fully insured, and you can see the descriptions here at the top of page four. the blue shield plans . access plus in trio are flux funded plans. the select epo, which again is therefore max. medicare families. same with doctors, mpo and we'll review what the enrollments look like that are united healthcare administered. those are actually self funded plans. the provisions and factors that feed into the rating process or illustrated on page five. certainly prior period claims in this case looking at 2022. claim experience factor in health care trend inflation factor, which

accommodates price utilization and new technology influences. any sort of designer headcount changes, administrative and other fees and then the acid pedrosa specific cost elements. um all factor in to how the underwriting is performed for each of the plans. and as we reviewed in the last presentation, these are the recommended rate actions, including what's boxed at the top of this chart. the rate recommendations after rate stabilization adjustments for the access plus and trio plans and the corollary united healthcare plans. um it is important to note in the footnotes. the um, in particular the after rate stabilization adjustment does capture both the normal, um, board policy rate stabilization adjustment that was reviewed and approved in march as well as for this

particular rating cycle, the impact of the sutter legal settlement by downs. and then page seven again just provides a comparative chart of proposed total cost rates across each of the plans with those proposed increases. for most active employees, those in city county of san francisco with the mou contribution sharing approaches , um you can see the two approaches does very by employee um so when we see 93 93 83, those are percentages paid for out of the total rate for each of the three dependent tears employee only employed plus one play, plus two or more. as well as the 196 83 approach that applies for some employees. and then early retirees. the employer contributions you'll see and then how the member

contributions are calculated from there are based on city charter language where there are three elements to the employer contribution. the time county amount, which was approved in march. what we call the actual difference, which is essentially the difference in rate total rate between active employee single coverage. and early retiree single coverage, so to kind of bridge that cost difference, um for early retirees versus active employees in the employer contribution formula, so that's the middle of these three stacking bars. and then finally, the retiree property contribution, which provides basically 50% of what's left after the first two. um for both the employee only or or excuse me, retiree only to your as well as the retiree plus one tier. there was no incremental city contribution past the first

dependent for retirees. so um other presentations will have this. um but i just wanted to make sure we covered this in this presentation and everything i talked about here will apply. in the subsequent. to recommendation on page 11 for health service sport action today is to request approval of the blue shield access plus h m o and united healthcare select e p. o plan renewal proposal. in other words, the broad network plan for 14.4% read, increase the more narrow network plan the blue shield trio h. m o united healthcare doctors, mpo proposed for 2.9% rate increase, and then the resulting rate cards that are included in this material. so again, i'll provide commentary. for the active employee rate cards, even though there are other contributions strategies across the employers . what shown are the two prominent employer contribution

strategies for city county of san francisco? in the early retiree rate cards are shown for those who aren't full city contribution levels based on dates of hire and length of service. so first just, you know, talking a little bit more. um this is really the first cycle where we've talked about you, hc e pos alongside access plus and trio and if you recall um, there was the initiative leading to the approval by this board last june to realign the administrator. for individuals. non medicare family members who were in a family where there's at least one family member who has medicare. and is enrolled in the united healthcare. medicare advantage. p p o i think is, you know rent and ray and others have documented over prior board meetings at that point lot of administration issues with those

non medicare lives covered under blue shield one the medicare life was covered under united. so that shift happened, um, for 2023 approved by this board last june. and as you can see, the vast majority of lives in these plans are still administered by blue shield. you know, both in terms of the members, the employees and retirees. as well as the covered lives, but this does give a framework that many families now do benefit in those mixed medicare family situations from the consistent administration of united healthcare. so my comments from this point forward will be access, plus or trio, you know, certainly, that's what i'm used to presenting to this board. but i just wanted to make sure it was clearer that the rates that you would approve in this presentation today also apply to these you hc um, non medicare plans for the mixed medicare families. so the rate increases

again are based on 2022 climate experience on page 14 ministrations fees for blue shield plans, capitation costs. and large claim, pulling fees and then other rating components that will describe on the next page. there are no planned design changes proposed for these plans and of the 2024 playing near and if you look at the overall kind of weighted average combined increase across access, plus in trio, it's 10.9. the rate cards are do include medical and pharmacy claims, but not of rebates. so we do incorporate those for the pharmacy. uh again, the capitation charges ministrations fees. there are uh, large game pulling fees, which we'll talk about here in a bit. ah some small element for the federal patient centered outcomes research institute corey fees. as we reviewed with you and march there is a substantial

change because of the adverse claim experience in these plans in 2022, so there is a change in the rating element of the stabilization from abi up and buy down in 2023 to buy up in 2024. of the vsp basic plan. vision premiums are included in the rate cards. those stay at 2023 levels. $3. saying ability charge stays the same, and then the center legal settlement impact as well. page 16 just to kind of refresh on, especially why the large increase for access plus, you know, overall plan expenses. as we reviewed with you in march increased by 13% on a pull employee and retiree per month basis from 2021 to 2022. some of it was a substantial increase in large claimants we want from 28 people

incurring 500,000 or more in 2021 to 49 and 2022 prescription drugs, elevation and specially medication spending of 14% and then also. and i think president scott, you alluded to this in your comments, a elevation of prevalence of chronic conditions and, as reported by blue shield. to administer beatrice aspect in february and then communicated by me to the board in march. double digit increases in the prevalence of members in aggregate based on the aggregated data that's made available, um with conditions like cancer. musculoskeletal cardiovascular heart conditions and mental health. i think what we also saw and you know that you just as we picked apart the data. um you know, why is the

increased so much higher on access plus uh versus trio and in part based on conversations and data that we looked at with blue shield. a lot does have to do with price per service elevation for certain providers systems. that are part of the access plus broader network. that are not part of the narrower trio not working the bay area. the plan design is the same between access plus and trio, so that is not an influencer of cost differences. the same exact copayments across the board. between the access plus and trio plans. you know the distinction between these two programs really is in who's in the network. you know who's who are the providers that can be sought for those in access? plus versus trio, as you can see , there are many providers here in the bay area that are part of both networks. um, you can see that list here. there's others,

but i would say these are the 10 primary providers. some are physician groups, um like health physicians in brown and toland. some are, you know, health systems. um you know, like john mirror. um you know, some are particular facilities like california pacific medical center in general hospital. but you also see providers that are in access plus and not in trio. um, you can see those five at the lower left. that when we looked at average cost data for services for those particular physicians and health systems. you know, we did see higher levels of unit price, um, rolling through these providers relative to those who were in both trio and access. plus so this was a factor in the differentiation of the planned experience that we observed between access, plus and trio in 2022. so again, that elevated

claim experience did lead to the change rate stabilization. but the southern legal settlement does provide some relief in the ultimate calculation for the rate increase for 2024. and then you know, i alluded. excuse me in a few changes earlier. um the administrative fees are locked in over a three year period. from 2022 through 2024. 2024 administrative fee. the $49.50 sounds per employee per month. uh is part of a three year commitment that came out of the fall 2020 rfp process, however, because of the large claim, uh data that was observed for 2022 . and you know what i alluded to earlier. the large claim polling fee is increasing by 49% after a 12.5% increase enough through fee for 2023. and that

influences their renewal for both access, plus and trio. now there will be a new complex care population management program coming into place for access plus in 2024. which is currently in place with trio. with apologies to this board, knowing how you feel about the word concierge. it is called shield concierge. and it is believed to provide and added level of patient advocacy, um, and care management that again is now in place for trio. ah that will become offered in access plus in 2024 is that what's called the karen navigation service. um it's so the name blue shield puts to what it's called shield. hartsfield concierge. but it is a complex care and population management program that's now in

place for trio. not for access plus, but it will come into access plus in 2024 at no incremental fee. so without i'll transition page 21, just introducing the rate cards and the group's better aligned with these red cards. page 2022 is a comparison of 2023 and 2024. um member contributions at the top. on a monthly basis. employer contributions in the middle and total cost rate. um we're a gun , you can see the increases. um or high because of the high increase proposed the 14.4% of total rate of the reason that the employer contribution for retirees is not quite 14.4% has to do with the 10 county amount

. um, being one of the three elements of how the employer contribution is determined for retirees. and as you recall from the march meeting, the 10 county amount increased 3.2% so other elements of the employer contribution formula are increasing commensurately with the total rape. but because of the lower 10 county amount increase at 3.2% that is why the percent increases. for the monthly employer contributions for early retirees are less than the 14.4. page 23. you know same numbers as prior page for early retiree just showing it for 196 contributions strategy for employees. and then the rate cards. page 24 showing early retirees in the 93 93 83. contributions strategy for active employees. page 25 the

rate cards for the active employees for 196 83. so all of that is for access plus and then transitioning to trio on page 26 . you'll see the lower increase the 2.9% in aggregate. um you know with rounding comes out to 2.8% in some cases. um were largely you know everything kind of flows through, um, you know, with these changes. into the active and early retiree populations. so you'll see the rates of change pages, 26 and 27 and then the red cards for trio in the uhd doctors e p o on 28 and 29. so as i conclude. my presentation on page 31 just closing with the staff recommendation. that the health service board approve the blue shield access plus h m o slash. united healthcare select gpo

plan renewal proposal for 14.4% rate increase. from 2023 to 2024. the blue shield trio. hmo unitedhealthcare doctors. epo plan renewal proposal for a 2.9% rate increase from 2023 to 2024. and the resulting 2024 monthly rate cards presented in this material for these plans. president scott. thank you, mike. i'm but asked, are there questions of the board at this point, commissioner brussel i'd like to go back to slide 17. because i looked closely at this. i saw the huge rate for early retirees, especially so i was trying to figure out if possibly, i mean for blue shield, especially how the trio would work for them. so, um yeah , i spoke to one of the members of actually friend, too, and she and she explained some of the problems he's had with thrill. um she said, like when her

primary doctor wants to refer to somebody with a trail plan. they have problems trying to figure out if that person is in the network. the doctors have been having that he's had had that problem. and, um she said the karen navigation service she was on the phone for an hour and they couldn't figure it out. so, um. so these are some problems that i think it's really important because people would probably want to look at the trio. considering the amount of money they can change. so for us to be able to clearly explain to them who will be in that plan and who won't be in that plan. because sometimes you have a doctor that you know our group that says they're in it, and then they have some side things that aren't in it and like c p. m. c. central health. see, pmc says, you know they're in both. but then there's more in the

access plus, so it gets quite complicated. so i think during the open. it's really important that we be able to explain this to our members. because it's jefferson prices quite a bit, and it's very expensive. i mean, you're looking at for an early retiree. $1573 month. that's $236. more than last year. and that's like $19,000 a year. so that's. that's a lot of money for some people who maybe you know, or fiction income, obviously retirees and stuff. so i really think we really have to look closely at this trio, too, so people to explain it to people. um you know? who was in and who who's out. yeah, there seems to be the main thing was

find a provider. for that particular doing and the doctors were having problems. so um. and something else came up. but this is not really pretending to this. that in the hmos. you always have to go to your primary care doctor to get referred to a specialist. now this person has an ongoing problem as it with the gastroenterologist. so every time she sees the gastroenterologist, she has to see the primary care first. i mean, what a waste of money you're paying for the primary care and then you're paying for grassroot tolerance. and i kind of forgotten because i am in united healthcare, and you don't have to do that. but that really is something that should be changed within the plan when somebody has an established relationship with the doctor, they shouldn't have to go see the primary care doctor first. and that would be something for blue shield to look at and try to change that. somehow. i mean,

i remember back when i was in there. thinking to what a waste of time i'm going to this primary care doctor first charge them and then i'm going to specialist. so, um that's something i think that somehow should really be looked at. uh, director. yeah do you have any comment on that last comment regarding the involvement of the primary care physician? yeah you know, i shield his hair and can answer some of these questions directly, but it's my personal experience that you get authorization to see a specialist in multiples should that be necessary for your commission, so it's not like every time you need to see a specialist. you get that you need to get that authorization you need to get originally and then it needs to be updated on a regular basis, but not for not usually for every visit, and my speaking correctly. is there someone here from michelle that can stand and speak to this about how that process works.

after you have been referred by your primary care physician to a specialist, what is kind of the norm? in the plan. thank you. would you please eight? the microphone? thank you. thank you . tiffany gill of blue shield account manager. thanks for having me. um we do have it is exactly how um, executive director yan explained in the normal circumstances when you get a referral from your primary care physician, it is for an episode right for whatever it is that you're you know, being treated for. you do not need to go back to your primary care physician for each subsequent appointment, but if there might be something else that needs to happen, or if there's been some time in between, then maybe there would need to be some interaction with the primary care physician. but i'm not aware of that normally happening , and we can certainly look into any individual situation. um and

help with that. okay, so let's come up. i'll have him call you exactly alright or come to member services and then prove member services talk to the normal channels member services , but we're certainly here to help. thank you very much. maybe before you leave the podium. can i bring my question? yes just comment on this last issue, having been you know, a sub specialist with in service care before i joined kaiser, um i was recruited attempted to recruit by one health plan, not blue shield or you know healthcare. um where they only wanted me to see a patient once and so i declined to sign up because of that. and so i would, you know, basically say that most of these health plans do authorize multiple business for the same problem. and so that i think what you say rings true to my experience, historically, um, because just based on again my own experience the one issue. i

think the other issues are very important one and that is, um that when we look at slide 17, which has the major access, plus and trio providers and multiple medical groups. you know, dignity, hill, brown told and etcetera. so can we assume that any sub specialist in brown and toll and are both members of you know the access, plus and trio that there is that so that there's someone specialist can't opt out. so that if they are a hill, physician or dignity, or or you see physician through these plans that they are required to be in both is that the case my understanding is that we've created a special network within brown and toland for hss members. um i'm going to look into it a little bit further because i was taking notes, and i can certainly

research it and get back to you. but my understanding is there are some um, specialists within brown and tone in our access plus network that are not specialists in the trio network . i think that that's a problem . i really do think it's a problem again, having been the situation, referring patients to sub specialists? um, and a lot of times the people in the south specialist office either. don't know for sure what contract they've signed or or don't know how they're being reimbursed. and so this is the problem. um if that is the case, and so i think maybe if you have that relationship with brown tolan, you may want to look at all the medical groups here and assure us whether this is a situation only with brown and tolan or whether it's a problem with all the medical groups that are listed. in both because that is really, i think an important issue that should be clarified. especially when we want to

encourage people to go into trail, right? yeah i understand . and we do have our find a doctor tool that is set up specific for the sf hss network that is available. um we and we can we do make that clear and open enrollment. but we can definitely make sure that we're you know, doing that as again and then work with our brennans whole in partners. because really a lot of times it should be. when there's a referral. it should be the brandon's holen team. um that is looking at, you know, kind of who is in and out of the trio network for them. and the other thing that concierge service, so the navigation service or whatever it's called for sure. um i think you should look into that since this person was for an hour and never had a resolved that i definitely would like to. if you have a name, we can certainly look into that. yes. thank you for those points and terms of any early review or the results

of any early review that you have regarding positions being in both networks and how that is structured if you could come back to us a subsequent meeting, maybe in june. to talk about that that would be helpful in my pleasure. thank you. all right. are there any other questions? comments from the board. if not, i'm willing to entertain a motion. mr president. i'd like to make a motion that we approve and i'll read the three itemized recommendations. the blue shield access plus h m o e u ht select e p o plan renewal proposal. for 14.4% rate increase from 2023 to 2024 2nd to my apologies up two more with my long winded motion . the blue shield trio hmo and

uhd doctors. epo plan renewal proposal for a 2.9% rate increased from 2023 to 2024. and third and final. the resulting 2024 monthly rate cards presented incorporated within this presentation as presented alright. those recommendations can be found on page 31 of this presentation. and it's been properly moves that these recommendations as provided in described by our actuary this afternoon. b. adopted as presented and approved. is there a second? but we already seconded. i thought, well, you seconded it the first portion while he was still providing the 2nd and 3rd. so we do have a proper second on all three recommendations. and with that we will now have public comment. i would like to make a comment to. i just want to make very sure that during open enrollment, this trio is explained. clearly to everyone,

because if not, you're going to get all kinds of phone calls from people who went to trio and then found out they couldn't access their doctors. so, um i don't know how. detail that's going to be, but it's definitely going to be somewhat extra work. i think well, thank you for bringing that note, and i'm sure the executive director and the chief operating officer made note of that comment. director. breslin, commissioner president so at this point, we'll take public comment. thank you, president scott. public comment is now open instructions are being displayed on the screen for those watching on sfp of tv and webex in person. public comment when we first then remote public comment for those colors on the line press star three to be added to the public comment queue for those watching the meeting on webex click on the raise hand icon to be placed in the public comic you to speak. we'll begin with any in person public comment. and no one has approached the podium, so we'll move to our remote public comment. i'll check to see if there's any colors in the

public comment q at this time. we have five colors in the phone . cute at this time. one caller has specifically entered the public comment. q. at this time , we'll hear a brief pauses transition between colors. welcome color. welcome color. the they raised hand icon has been removed. so we'll give another five seconds to see if any colors would like to join the public comments you at this time. zero colors have entered the queue at this time. public comment is now closed. thank you. and with that we're ready for a roll call vote. roll call votes, starting with president scott president. how commissioner breslin commissioner canning commission supervisor dorothy. commissioner

follansbee commissioners umansky reluctantly, i it is unanimous. excuse me. will now move to item number. seven. agenda item number seven review and approve non medicare people. there we are. thank you. item number seven. review and approve non medicare p p o medical rx self funded plans, 2024 rates and contributions. this is an action item and will be presented by mike clark, with am my clerk, an , um, reviewing the non medicare ppl plan rating 2020 for our recommendations, i'll provide a renewal summary walked through the rate cards and, um, state the recommendation for household sport action. um i will not review again. the rate methodology profits as i reviewed that in the prior presentation, so what i would

like to do is transition to page 11. art to open with staff recommendation that that all service board approve the non medicare p p o plan. and non medicare people plan choice not available. 2024 playing near monthly rate cards presenting this material where the resulting total rate increase for the non medicare p p o plan including stabilization and settle illegal settlement rating adjustments for 2024 is 1.7. and the total rate increase for active employees in the non medicare p b o plan. choice not available, including stabilization and sutter legal sediment rating adjustments for 2024 follows the blue shield access plus unitedhealthcare select video rate increase of 14.4% just reviewed in the last presentation. so the commentary ah more follow just a reminder that the mou for city county of san francisco employees specifies that the employer

contributions for the highest cost plan. offered through us of petro sauce, which is the plan i'm presenting now are set to equal the employer contributions for the second highest cost plan, which is the blue shield access plus united healthcare select video plan. so this guides how the employer contributions are set for the non medicare p p o plan in the active employee rate cards, but noting that for the employee only tear 196 83 strategy in place. employees pay no contributions for any of us aviators, ourself plans and the employer contributions equal the total rates just for the employee only tear in each plan for 196 83 employer contribution strategy, and over and above their own are multiple strategies. um within broader, a survey to assess and the early retiree rate cards shown in this presentation of her early retirees earned the full city contribution levels based on the

dates of hire and length of service. so page 14 just a reminder that this plan is administered by two carriers. and has been since the start of 2022 when blue shield was named the plan administrator for most ppl playing covered lives, um all except those that are ministered by united healthcare. for enrollees in the p p o plan in non medicare split family covered lives more one or more family members medicare and enrolled in the united healthcare medicare advantage ppl plan. and you can see for the members, the employees and retirees the vast majority of fall under blue shield administration. um with 336 of the total 3353 covered lives administered by united healthcare. and so the recommended rate increases are based on 2022. climb experienced one of the 2024. the

administrative fees for each of the carriers and other rating components that i'll describe. there are no planned design changes proposed for this plan and 2024 playing here on page 15 just listening out, um, all the elements that go into the right development for the self funded plan. you'll note the claims medical and pharmacy, not of rebates, administrative fees. the by operates stabilization. there was a buy up for 2023. it's grown a little bit for 2024. the vision plan premiums for the basic plan, which remain unchanged, as well as the $3 sustainability charge. and the one time provision for the subtle the legal settlement raining by down as the board approved in april. we reviewed plan experience for the ppl with you at our april meeting. at that time we talked about medical climb experience increasing 8. per covered life

in 2022 versus 2021 prescription drugs actually increased at the lower rate, because the overall um kind of cost of prescription was mitigated in part by the rfp process that occurred into the 2022 planned near someone you combine everything to 7% recovered life increase, which is right at our annual cost trend. assumption based on what we're tracking nationally. the difference in the rate stabilization reserve adjustment creates a small, unfavorable difference in the rating for the plan for 2024, but more than offset by the one time uh, center. what legal settlement amount almost $3 million, but as commissioner calls be noted, um you know this. this is a one time offset and we will need to consider in 2025 that this amount will not apply, or at

least whatever incremental funds come what nearly be to this extent. blue shield did commit to no increase administrative fees, including those for accolade delivered services. from 2022 to 2024 as part of the fall 2020 rfp process while they're just nominal increase in administrative fees 1.5% for united healthcare. just to remind when we talk about the choice, not available rating. this was a concept that was introduced several years ago. to help lower the member contribution paid by members who live in geography ease where either the non medicare p p o plan is the only choice available. so the majority fall in that circumstance or the rare instance where kaiser is available, but not a blue shield hmo. yeah, vice versa. and so you can see the distribution of enrolled members, um, across the

plans between the non medicare p p o plan. with the higher contributions from members. and the choice not available, which gives contribution relief for members and the p p o plan, so the vast majority of active employees um, live in areas where the hmos are available, but you can see that this supports more than half of the early retirees that enroll in the ppl plan. um and so, you know, especially for active employees and the hatch act remarks scenarios early retirees living outside the bay area, it does help lower the member contribution and you can see the how the rates are determined for active employees the same premium rates, including all the rate card elements. in contributions as the blue shield access plus plan for early retirees. the same premium rates is non medicare ppl plan, but it leads to lower retiree contributions relative to the

non medicare p p o plan based on how the city charter formulas are replied so on page 20. um just lead in on the red cards that you'll see. you know, for active employees, the two for the 93 93 8396 83. um model and again, noting how. the employer contributions are set in the resulting member contributions based on the m o. u. s. page 21 shows a comparison. uh of the man medicare p p o plan where again the employer contribution for active employees is based on the same employer contributions access plus some when you have a 1.7% total rate increase in a 14.4. employer contribution increase, you know that leads to the significant decrease in the employee contributions, you know for the active employees. and for early retirees because of

the city charter formula being mostly driven here through the 10 county amount, you know, you see relatively nominal changes in the member contributions. from 2023 to 2024. and then page 22 showing up for the 186. strategy the rape cards themselves for the non medicare p p o plan. shown on pages, 23 and 24. for choice not available again. the increases lucky but keep in mind that the member contributions are still significantly lower than what we reviewed for the regular, non medicare p p o plan because of the dependency of the rates linked to the act access plus plan raids, you know, that's why you see the larger percentage increases, but a gun you know, noting that the actual amounts from member contributions for

2024 for choice not available remain substantially lower than those who have choice and elect the p p o so the change numbers page 25 and 26 and then the red cars for ppl choice not available on pages, 27 and 28. so with that i'll transition to page 30 close. uh, with the staff recommendation that the health service board approve the non medicare p p o and non medicare bpo choices available 2024 planned near monthly rate cards presented this material, resulting total rate increase for the nun. medicare pto plan. including stabilization and several legal settlement reading adjustments. for 2024 is 1.7% in the total rate increase for active employees and the non medicare pto plan choice not available, including stabilization and sutter legal sentiment. rating adjustments for 2024 follows the blue shield

access plus h m o unitedhealthcare select gpo rate increase of 14.4. president scott thank you. are there questions from board members regarding this presentation or any aspect of it? if not, i'm willing to entertain a motion. i'd like to move that we approve the recommendations of the staff . um as outlined on the slide 30 , including the non medicare p p o plan and on medicare, ppl plan choice not available. 2024 plan yearly monthly rate cars has presented the toll resulting total rate increase the non medicare p p o plan, including stabilization and the essentially one time center. legal settlement rating adjustments to for 2024, or 1.7% and fire the toll rate increase for active employees in the non medicare p p o plan choice not available in clean stabilization

and center. legal settlement rating adjustments for 2024 following the blue shield access , plus h m o u. h c select epo rate increase. equally in 14.4% 2nd. it's been properly moved and seconded that the actuarial recommendations along with the staff. as presented in this presentation be approved. and with that we'll now open it up to public comments. thank you. president scott. public comment is now open instructions are being displayed on the screen for those watching on sf tv and webex in person. public comment will be first and the remote public comment for those colors on the line. press star three to be added to public comic you those watching the meeting on webex click on the raised hand icon to be placed in the public comment. q to speak will begin with any in person public comment. and no one has approached the podium, so we'll begin our remote public comment. we have $5 on the phone line. zero colors have entered the public comment. q at this time,

a reminder to all colors on the line press star three to be added to the public comment. q to speak i'll give five more seconds does he have anyone would like to join the public comic you at this time? zero colors have raised their hand at this time. public comment is now closed. thank you, with the closing of public comment will not take a roll call vote roll call votes starting with president scott i. president. how commissioner breslin commissioner canning. supervisor dorsey commissioner follansbee commissioners advance key. i. it passes unanimously. and with that we are slightly ahead of the time schedule that was provided to me and i would like to at this time. declare a recess of 15 minutes and by my chronometer were to 2021. so we

leave back at 2 35. thank you. we're now coming out of our recess will have a role called for horn purposes. thank you, president scott. a roll call vote orebro call starting with president scott president. vice president. how president commissioner breslin here. commissioner canning present supervisor dorsey. commissioner follansbee present. and commissioners. nancy president thank you. we do have a quorum. and at this point we will now move to item number eight. thank you. president scott agenda item number eight is review and approve kaiser permanent. take california medical rx fully insured, non medicare hmo plan

2024 rates and contributions. this is an action item and will be presented by mike clark with a m. mike clark and here to present the kaiser permanente, california. ah active employee and early retiree 2024 plan rating recommendations right. i'll provide a renewal summary. go through the recommended rate cards were active employees, an early retirees and the recommendation for health service board action. ah the appendix information does include underwriting premium rate build up for the rates that will present today. i'll skip through the race setting methodology, preface just noting that this is a fully insured plan. um so the rates are set by kaiser permanente, you know, certainly the underwriting reviewed by me, um, as the lead actuary. on page 11 staff recommends that the health

service board approved a 10.86% ensured plan premium increase from 2023 to 2024 for active employees in early retirees in california, enrolled in kaiser permanente. based on fully insured plan rates proposed by kaiser for the 2024 planned near and changes to the kaiser hmo plan design to match major plan design features currently in place for the blue shield of california and health net cannot be carried remote plans as outlined in this presentation, and then the resulting 2024 playing near rate cards for the kaiser, california hmo plan and section three b of this presentation document. for active employees and early retirees, reflecting rates based on recommended plan design changes as contained in this presentation. noting that this presentation contains two sets of 2024 kaiser hmo rate cards for health service board consideration. uh one in section

three. a obtained status quo or no plan design change rate cards from for 2024. as well as section three b that contains, um rate cards, reflecting the recommended plan design changes in this document for 2024. and the plan. design changes are recommended to mitigate the kaiser hmo rate increase for 2024. on page 12 the rates and premium contributions. um you know, have the detailed exhibits and again as i noted earlier, the appendix does contain an underwriting premium rate build up. um exhibit for your review. the red cards include for the active employees for a city county and san francisco employees for the 93 93 8396 83 strategies, noting there are other employer contribution strategies across other employers and sf hs sauce in the early retiree rate cards are shown for the early retirees who

earned the falsity contribution levels. based on dates and length of fire of service, with the employer contributions determined based on formulas outlined in the city charter. so looking ahead to page 14. the 2024 tizer total premiums for active employees and early retirees on the status quo design basis or increasing 12.5% for medical and pharmacy coverage. this follows a 3.9% rate increase that occurred for the 2023 planned near for the rating development for 2024 really reflects two elements about 4% of this renewal is driven by plan experience. from february. 2022 3rd january 2023 trended forward 23 months so consistent with the planned near 2022 experience is was reviewed . um at our april 13th health service board meeting. the remainder about 8.5% driven by

an expected increase in expense levels in the plan into the 2024 plan here is communicated to us by kaiser. influenced by labor shortages, inflation and supply chain disruptions, increasing demand for care, increasing prescription drug costs and provider challenges on the financial results shown for the enterprise wide kaiser permanente system. you can see on page 15. as reported by kaiser in early february. 2023 operating expenses exceeded operating revenues in 2022. uh which generated an operating loss for the kaiser permanente organization for the first time in 20 years. pfizer did report their first quarter of 2023 financial results on picking me up fifth that is also shown on the right side of this chart. um q one did produce, um, operating

income. uh to a small extent, the footnote contains more information. um on what could be expected for the remainder of 2023, you know, based on historical patterns for q one. so this information above in the stable contributes to the kaiser's enterprise wide revenue increased forecast. uh in other words, the insured premium rates to their customers into 2024. um page 16 just documents background on the kaiser permanente structure. it's an integrated care delivery system , providing both the health care to the member and the insurance product. unlike the network model health plans, like the other plans offered through us of sauce, kaiser's budget is developed to ensure the revenue needed is available to provide care. for their members, as well as the fixed costs for their delivery system expenses or budgeted in advance to help

ensure the operation of their care delivery system contracting of outside services as may be needed for members and the administration of their health plan, including capital expenditures. kaiser permanente is health system expense increases or expected to be realized more immediately than what may occur through network model health plans were impacts will be expected to phase in as individual system contracts with those network health plans are updated. typically every 2 to 4 years. would you please translate that? into yeah. smaller english. kaiser's health system, expense increases are expected to be realized more immediately. what does that mean ? sure so for a typical network health plan, they have staggered contractual dates. with their health systems. where a given health system i mean, let's say

health system a may have a contract expiration on their fifa service pricing at the end of 2023. system b may have expiration at the end of 2024. you know, typically, those contracts are, you know, locked in on a 2 to 4 year basis. kaiser permanente and essentially has one health system. um, so unlike you know, we reviewed earlier the chart with the blue shield. there's dignity. health. there's sutter health. there's stanford healthcare. there's brown and toland physicians, etcetera, um , within the kaiser world. it's essentially the kaiser permanente. medical group. and so, um. you know what's happening within the kaiser health system now is um you know, review of labor costs that are happening. uh perhaps, um, you know, individual negotiations that could be happening with various aspects of their labor. um increases

that are occurring within the prescription drug purchasing environment happening more immediately. um so in other words, those costs kind of almost roll through as incurred within the kaiser system versus um, locked in, based on a multi year contract. that health plan like blue shield may have, um with various systems that have staggered dates, so does that help caught the cost flows or in this particular instance or not staggered in kaiser, whereas they are and other health systems correct, so they see their costs all at one time. exactly and you know what's been communicated to me. in separate conversation, separate from that's a beatrice aspect is general john kaiser leadership discussions. is some of these expense increase factors have

really been more prominent sense . initial renewal's were released. by kaiser at this time last year for 2023. um you know, i've heard commentary that just says if we had it to do over, we probably should have been asking for higher premiums for 2023, based on how expense levels have developed since we released generally. client renewal's, you know about this time last year, all right. thank you. questions uh, so just to be clear, even though we're renewing for one year, what you're saying is the health plans. negotiations will depend upon all these other factors and their own negotiations for pharmaceutical services, or, you know, physician or from whatever they're they're doing this maybe in a different cycles. as well. so even though we're renewing for a year, with all these plans , their cost me be staggered a bit more so we may see a much

higher rate in a year or two from some of these other plans as those other contracts expire , and they take a big hit. big jump is that what is that? some of the we can anticipate it is possible. in that is a conversation that we're having with other other of your plans that are there, not work model plans to truly understand. what are the timing of next cycle of you know, basically fee negotiations with the various health systems. but they may have. so we're relying on for instance. health net blue shield unitedhealthcare to give us their best 2024 forecast now. so bad that factors into the underwriting, um, for the health plan. so for instance, the blue shield renewal that, um, for the hmos, um, that was discussed earlier. that ostensibly factors

in expectations for blue shield on the price levels. that may escalate from current into 2024. but we're relying on them to predict those as accurately as possible. right now. to reflect what's anticipated to be a 2024 cost spaces. commissioners have an ski. so would i be correct in calling this front loading? is that what kaiser's doing their front loading so that they can spend the next couple of years saying oh, no change. but their front loading the next couple of years into the rates were looking at today. yeah so my in my several discussions with, um , you know kaiser street facts wearing heuser leadership. my understanding is they're taking an enterprise wide. view to harass, set the healthcare trend and maybe better explained you

know, visually, as i answer your question through of review of page 17. you know, what they're looking to do is look at their enterprise wide. forecast for all operating expense for 2024. look at what revenue they feel. they need enterprise wide. um to achieve the financial targets. um sought for 2024. that incorporate the best forecast for their enterprise wide 2024 expense levels. and so that is factoring into, you know, number one and number two on page 17, you know, determine the amount of total revenue needed to cover those expenses. and then calculate that amount of expected revenue. enterprise wide. and then from there set group's specific rates. now, i will say, um, with the renewal's

i've observed from kaiser. um so far year to date for 2024, playing near both for us of hss and for other clients that i have with kaiser. rates are clearly higher rate increases are clearly higher going into 2024. for every client that i've seen relative to what i've seen in the past. for kaiser and as i mentioned before you know what this 12.5% proposed increase with no plan design changes. about four of that is based on plant experience. you know, the remainder is based on essentially this formula or or factoring on page 17, leading to that 12.5. rate increase that they have quoted for us about the sauce. so my guys have a question. i'm sorry if i may

just understand it. so um, when you said that, in hindsight, kaiser wishes that had said it's traits differently. um, i'm paraphrasing, of course, because the expenses or whatever came in a little bit higher than expected. so are you saying that in your little pic picture here number one. they underestimated that and number two. they uh, or they, basically they were off in their in their guesstimates. in this picture. and i think. again if you look at the q one, you know, going back to the um, couple prior pages. just looking at the first quarter. operating revenues and expenses of 2023 as it was released publicly mike kaiser citizens available public information. the operating expenses of 25.0 million or billion came in just slightly below the operating revenues.

but there is an expectation that operating revenues quarter to quarter will stay relatively constant through a year because most of that is premium. most of that is calendar plan premium. that really won't change the course of the year. relative to operating expenses, which will typically grow some quarter to quarter throughout a year. and so um, you know, again. i don't want to speak for the kaiser organization. i'm not here to make forward looking statements at all. but it could be inferred that you know on this trajectory it is possible kaiser could in her an operating loss, you know, for the full 2023. if similar patterns to how first quarter finishes and 24 year if that plays out that way for 2023. thank you. all right. are there any other questions continue.

you're not done yet. no she's not asking. are there any other questions on that point on this point of kind of the revenue determination, operating spence , which is really the crux of this all right. please proceed, michael. thank you so transitioning to the plan design alternative for health service board consideration. the there are planned design features for the kaiser hmo plan that are different, you know co payments that are lower. ah then copayments in maximum out of pocket in place for the blue shield of california and health net canopy carried remote plans. and we have a chart on the next page of the prominent features that are different between the plans and so given the high renewal increase, and, you know, kind of alluding, i think vice president how to a comment you made at the last board meeting just to least explore what potential plan design alternatives could do for the

premium. uh there is a recommended plan design change said that would lower the needed rate increase. um from the 12.5% to 10.86% which is the 1.64. percent difference in the rates. and page 19 illustrates what the plan design feature is the major plan design features are that would be proposed for change. current for 2023. you can see the categories on the left side . the current amounts for the kaiser hmo in the first column. and then recommended amounts for 2024 that would match the plan design provisions. for the blue shield and health net cannot be care hmos. so the kaiser red cards on page leading off from page 20, you know, reflect these fully insured premiums. no change the basic plan vision premiums. no change to the $3.

um as a waitress as healthcare sustainability fund charge. um and you can see the employer contributions. three components that factor in early retiree. contributions the active employee rate cards are shown for the 93 93 83 and 196 83. so um, next to section three. a. so just be clear. section three a are proposed 2024 monthly rate cards for the kaiser, california non medicare age demo plan if planned design remains the same. it's 2023. and what you'll see embedded within the information so on pages 23 and 24, you know, showing what the changes would look like for both active employees and early retirees. um you know, the 12.4% is because of this no change division. no change to those sustainability but embedded within this or the overall kaiser premium increase

of 12.5. against slightly lower employer contribution increase in 12.5% for the early retirees for the employer because of the 3.2% increase in the 10 county amount. um i will also note for the early retiree retiree only category. um it would generate a member contribution of $14.90 on a monthly basis where there is no monthly contribution today. so 93 93 83 for the actives shown on page 2396 24. and the resulting rate cards are shown on pages 25 and 26. so again, i called this set of ricard's section three a is you? consider today's recommendation with no plan design changes. with the

plan design changes recommendations that we reviewed earlier, section three b. contains again, formacion. on monthly renewal, premiums and contributions. first, the change from 2023 to 2024 for the active employees and early retirees. page 28 for the 93 93 83 active rate card page 29 for 196 83. and then the corresponding rate cards themselves under a with design changes, as recommended this document on pages 30 31. so again refer to this as section three b as you, um, consider so in summary page 33 close that staff recommends that the health service board approved a 10.86% insured plan. premium increases in 2023 to 2024 for active employees and early retirees in california enrolled in kaiser

permanente based on fully injured plan rates proposed by kaiser. for the 2024 playing near and changes to the kaiser intermodal plan design. to match major, uh, design features currently in place for the blue shield of california and health net canopy carried remote plans is outlined in this presentation. and the resulting 2024 plan your rate cards. for the kaiser, california hmo plan and section three b of this presentation document. for active employees in early retirees, reflecting rates based on recommended amazon changes as contained in this presentation. with the kaiser hmo plan. design changes recommended to align major design features to those currently in the blue shield of california and health net h m o plans and domesticate. the kaiser hmo plan. 2024 renewal rate increase president's cup. are there questions from members of the board regarding ah, the

descriptions of both options that actuary is presented over any other aspect of his freezing station. mr president, if i may and thank you, mr clark for your mr channing. for your detailed presentation. um i'll, uh, echo the comments of my colleague, commissioner stefanski with reservation and a lot of trepidation about digesting what you explained, um meyer, as aboard our mandate clearly is to ensure that our priority is on our membership. and with that also comes up balancing act between our individual members in the system as a whole in this may bleed over into, uh, madam executive director to answer this question, but as we digest and consider and debate and discuss the two options if this board is unable to come to a consensus on anything, my main concern is a vast majority of

our membership, active and retired, rely on this plan for a variety of reasons. and, um i guess my question is, we begin our conversation as if we're unable to reach any sort of consensus. um what? next as it relates to the system and what our next steps would be? i, um. the scenario in which this sport cannot make a decision i don't think is unprecedented. um and so i think it is the charge of the charter for this board to, um, past the rates. um, and if there's um. concern about the, uh. rates that are presented then we need to hear them in a public forum. we do have the clock that i mentioned during the rates and benefits calendar presentation that we must send

this package to the board of supervisors, um on or before june 16th in order for all the approvals to take place in order for us to be able to issue insurance cards are plans to issue insurance cards in january, 1 so it is a it's a challenging, um, responsibility that this board has, but that that is what it is. and um i we, um. have seven members of the board and so there may be a split. but there um there can be about that. uh, if the board. doesn't approve this. we're going to be stuck. i'm gonna look at my city attorney here to figure out what the next steps are. but um, i'm hoping that the diligence that our team has put into this recommendation, um, is understood, and if there's any questions about that, we'll be happy to answer it. this i think , um, you realize has has not

been easy for either party in this negotiations because they kaiser does play a significant role. um and, um, i'm i'm concerned that our board needs to have a full appreciation, um , that the increase for blue shield was quite steep. as well and is serving a large number of our population. i also want to give you some level of not real comfort, but, um understanding. the governor of california has appointed health care affordability board that has met twice. i attended virtually the meeting this week and as i was appointed to the advisory committee, this problem of the increase in cost of healthcare is certainly felt throughout california, if not the whole united states, so i think we have to, um put this decision as difficult as it may be. we have

to put it in context. we are looking for ways that we can, um spread. the pain is the right way of saying it, but, um, we're in a we're in a particularly difficult time with the budget in san francisco, you know, approaching the billion dollars billion dollar loss. and at the same time, you know, wanting, you know, having recruitment issues and wanting to, you know , hire more people, and this is a really rich as we've seen in the presentations that mr clark has done in the past is a very, very rich benefit, which we all enjoy. we'd like to keep it that way as much as we can. um, and it requires, i think, sort of an all in strategy that everything that this board can do. i think, um president scott mentioned at the beginning of the meeting the tools that are available to this board in order to try to manage the cost at this point thank you . are there other questions?

comments commissioner stravinsky . i'm going back to page 19. and i'm concerned that. i mean, i can see going from a $20 copay to a 25. um in a couple of categories, um, not thrilled about the pharmacy brand drugs, but i understand where that's coming from. my basic issue is inpatient hospital and outpatient surgery. those copayment adjustments are extreme, in my view. and i'm wondering if there was any opportunity or if kaiser presented any other or if there was any other opportunity to discuss to discuss with kaiser some kind of mid level changes that weren't so excessive from 100 to 200, or from 35 to 100. um in these cases because i see that um i realized the

utilization and as we're getting older um, and with what's left of covid that people are probably using inpatient and outpatient. especially the outpatient surgery a lot but these are huge. copay increases . what? we're options here. so the recommendation was to select this alternative. to create the alignment to the other existing hmo plans. and in a sense of doing so maximize potential rating document for any planned design. change alternative. um you know, we can essentially outline any degree of change between current and propose. we didn't want to go farther than what's in place today with the blue shield and health matt

hmos, certainly for this recommendation. um but this particular alternative was selected. to bring as much of the rate document change. into the recommendation. um, while. having a plan design that has basis in other hmm. offerings for me as a beatrice, us. thank you. can i? yes the strength of this recommendation is exactly that that it does bring everything in line. i just want to, um throughout some cautionary comments. um one is, um that you prefaced your first presentation on sort of the methodology for all the plans regarding on the fact that we saw less utilization um, because of covid or whatever. um, and there are four main areas of concern or cancer, muscle,

skeletal cardiovascular disease and mental health. and although the studies focus often regarding the effect of increased copays and share of costs on people with, um and who are not don't have employer subsidized healthcare so either through 88 to the americans to the a, c a or through, um, through other, um, you know, government sponsored health plans. um the impact is pretty consistent, and that is that it decreases utilization. um in general because even the small differences and i particularly pointed out in terms of the pediatric, those families there is no differential. so those you know individuals with 123 or four kids have to pay this copay for each of their children. um well now, obviously, certain things like immunizations will be covered, etcetera. i'm assuming and all there's no change. but and so i don't know

whether if they come in for just an immunization, whether they get charged a copay or whether that's covered free of charge without the office visit surcharge, but but i do think that, um, that number one this four areas, at least three of them strongly, um, benefit from , um, made from sort of, um screening cardiovascular disease. cancer um, and mental health number one, and so we seem like we run the risk of increasing that if we decrease utilization in those areas, a number two is that we need to be very clear that number one. we're shifting costs from the well who don't use any services or have any prescriptions to the ill. this is going to benefit. this is going to hurt those people who who are ill who do need multiple visits with primary or subspecialty care and are on medications. it may encourage our members to say to their providers. she is there a brand name is there a non branded generic drug that i can use? because my share costs and maybe particularly in the area of mental health, but there's so

many, um, advertised. drugs for mental health conditions that maybe there are generics that might be better utilized. so this may help our members maybe refocus some of their control over these costs. um but i think in general number one. this is the wrong direction in general, and so if i vote in favor of, you know you're the modification. and to the to the benefits this year. trust me, if this is becomes a trend, um, and subsequent health plan offerings , i will be very suspicious. um about this approach to cost because you know there's no way around that the main benefactor from our approving the new plan, as recommended is to the city. um the ship. the chair. cost goes up in both scenarios for our members, but clear the city gets the largest percentage, um

, benefit, and so do we want our employees and early retirees who are not, um, who are non medicare, um, to make a voluntary contribution, essentially to help the city out at a time when the city is under tremendous financial press pressure, and that's what this does is ask them to do that. alright. are there other comments? well the only comment i have is, you know, the decision is, do you want to increase the copays or do you want to increase the monthly premium and. i used to think which would be better years ago, there was always kind of well, the monthly premium would be better or vice versa. and for a certain step categories like the actives frequently don't pay this anyway. the unions pick up a lot of this stuff. as far as the premium. they don't pick up the copays if i'm correct and so for them. to increase the

monthly. contribution rather than two copays so but for the early retirees you know, they get hit both ways. so. it's for instance, page 23 and page 28 that maybe a helpful comparison. ah to look at the 2024 member contributions. that would occur on page 23 for the 93 93 83 actives as well as the early retirees, um, under the south squad design and then page 28 the same populations for the with changes, so the top row are the member contributions. yeah. so the status quo for disobeyed clear for the retirees on page

23 is indicated at $14.90. and then when you that's with the current plan design correct. with with the design changes that changes. to zero actually $8.80 dollars 88 cents, so it's $14.90 versus $8.88. correct about a $6 monthly differential. and are they currently paying anything? ah that tear early retiree retiree only as paying zero contribution today. alright so under either plan, there will be some costs as a change in cost to these retirees correct just to be clear on that point. yeah. definitely. are there other questions or comments from the board? i'm ready to

entertain a motion. i just have one comment, so i don't expect your answer. i'm just expressing just i think that the pickle that i feel like the board is in because we do have our fiduciary responsibility to um, the trust and to the membership and it feels like here we have to it's his delicate balance of how to consider both. yeah the sustainability of plans and the costs and the impacts of that so . thank you. commissioner. how. mr president, if i may make a motion but a comment first based off of me our conversations and what i've heard from the membership. um i think the true

value of this plan for a majority of members that i hear from, uh, tends to be the low copays and i think to commissioner fans, bees comment. earlier our concern and care for our aging population any sort of disincentive to receive ongoing care i view is, um more of a harm to the system to our members than to try and balance out, um and align with with other plans. so with with that being said, i would like to make a motion. uh, mr president. that we approve. um. with my colleague, commissioner savan skis. comment with with great reservation, uh, the status quo plan design with the rate increases as presented and incorporated within the right cards. and again, that is the status quo plan. design is what

the motion is for. and that is the three a section rate cards just to be clear, right. so with that restatement, or al reinforce that particular point . that would be the monthly rate cards and this presentation starring at page 22. so it's option. three. a is the proposed motion. is there a second? and that's with no design change. no design changes, a second at alright, it's been moved and seconded. that we adopt. the option three a. as presented in this presentation by our actuary. which results in about 12.5% increase in premium rates. for members protect members participating in this plan. that's the motion. all right. so

on that motion, we will take public comment. thank you, president scott. thank you, president scott. public comment is now open instructions are being displayed on the screen for those watching on sf, give tv and webex in person. public comment will be first and then remote public comment for those callers on the line press star three to be added to the public comment queue for those watching the meeting on webex. click on the raised hand. i can't be placed in the public comment q at this time will begin with any in person public comment. welcome good afternoon. my name is bianca polo vina and i am a city worker, kaiser member and i'm also an elected officer in my union i f pte local 21. so i'm speaking to you today to you today in my official capacity as an elected officer of my union, um, a little bit more about us. local 21 were the second largest miscellaneous public sector union here in the city and county of san francisco. we represent about 5800 c. csf employees. and over 2500 of our

active members are today enrolled in this kaiser hmo plan . fpt local 21 agrees that the status quo plan being identified here today as three a is the best option for our membership right now. um, as this. commission has pointed out earlier. the significant changes in the proposed plan design changes to increase the copayments would have real and substantial everyday costs for those over 2500 of our members, and that's just for our local. that's not for the other. city workforce. so we are asking the board here today for two things to vote in support of this motion to preserve the status quo plan for the coming plan year and, um, we're also asking this board to engage with us in

a proactive way not only being transparent with labor with the workforce in your negotiations with providers, but also on ways that we can all collaborate better. it's no surprise to anybody here. that the city and county of san francisco is one of the largest employers in san francisco and in the entire bay area and collaborating with the workforce here that tens of thousands of city workers who actually make this city run is only going to provide benefits for everybody. employer employee and the community of like, thank you. thank you for your comments. is there other comments in the room? board secretary. i see none. we'll move to our remote public comment and i'll be checking to see if there are any colors in the public comment. q at this time. we have four colors in the phone line. one collar has

specifically entered the public comment. q at this time, there'll be a brief pause as i transition between colors. welcome collar. yes good afternoon. this is frank brass from the san francisco municipal attorneys association. i'm a board member, and i represent basically a group of public defenders. can you hear me? can you still hear me? yes. okay public defenders, district attorney's city attorneys and various other legal public employees i would join with the last commenter. we are. we are very concerned about the rate increase, how they were arrived at and we believe that at this point, they have not sure i would enter a general objection. the rating. i i'm sorry. we'll call her. we were having a hard time hearing you is this better

? yes. proceed okay. i'm so sorry. moment if you would start you said i think we heard you up to the point that you said you had a general objection. that's the portion that we did not hear. yes we have a general objection on behalf of our members for the increases as set out in today's presentation. and may i just for clarification the increases to the copayment, uh, option that was outlined and uh , option b or the increases to the premium right under the status quo, which is where which is the main motion three, a so which increases or is it all of them? all of them, all right? thank you for that clarification. no problem. thank you, caller. i yield to anybody else. who wants a comment? thank you. thank you. muted. we still

have four colors in the phone line. zero colors have raised their hand at this time. i'll give you five second, um, brief pause for anyone who wants to join the public comic you at this time. zero colors have raised their hand. public comment is now closed. all right, thank you. we are now ready to do a roll call vote like the have anything else you want to add? at this point, nothing more. i just came up in case there were any further questions before the vote. alright excuse me. voting president skip, may i ask? i have a technical question on the agenda, the staff recommendation in the presentation was to adopt it with planned design. and so i believe the motion was different than the staff recommendation, and i just want to call that to your attention to see procedurally. there's anything that we need to do. thank you. the staff recommendation was for

three b in the presentation, the motion that was made and properly seconded and discussed is that we do not accept the staff recommendation that we vote on option three. a the status quo design with the resulting percentage increase in the right cards that are identified in that option, starting at page 22 in the presentation. so if we're all clear on what we're voting on i will now call on the board secretary to call the wrong call . vote thank you call vote, starting with president scott. i president. how commission president. hi. mm hmm. excuse me. here. one more time. commissioner breslin i commissioner canning i. supervisor dorsey. commissioner

finds me i and commissioners bronski i. i believe the roll call vote results and a 6 to 1. ah voting. as a result, the motion is carried. with that i would like to thank ah, my clark and his team. and i'd like to thank the hhs staff and leadership for their diligent work on all of these proposals that we have seen today. ah i know that it's been a lot of work down to almost the last minute if you will. to look at this. look at these options and the resulting make the resulting recommendations. so thank you. thank you if i may ask executive reverie and there is a hold for

june 12th. are you able to address that or it still remains a hold on the benefit rate. some medical company still remains a whole because it really has to do with how well received the medicare plans are. thank you, okay? all right. is there anything else? as far as i can tell. we're ready to now take up item number nine. and it requires no discussion and i, as the chair declared this meeting of the health service board adjourned. love that couple.

the tenderloin is home to families, immigrants, seniors, merchants, workers and the housed and unhoused who all deserve a thriving neighborhood to call home. the tenderloin initiative was launched to improve safety, reduce crime, connect people to services and increase investments in the neighborhood. as city and community-based partners, we work daily to make these changes a reality. we invite you to the tenderloin history, inclusivity make this neighborhood special.

>> we're all citizens of san francisco and we deserve food, water, shelter, all of those things that any system would. >> what i find the most fulfilling about being in the tenderloin is that it's really basically a big family here and i love working and living here. >> [speaking foreign language] >> my hopes and dreams for the tenderloin are what any other community organizer would want for their community, safe, clean streets for everyone and good operating conditions for small businesses. >> everything in the tenderloin is very good. the food is very good. if you go to any restaurant in san francisco, you will feel

like oh, wow, the food is great. the people are nice. >> it is a place where it embraces all walks of life and different cultures. so this is the soul of the tenderloin. it's really welcoming. the. >> the tenderloin is so full of color and so full of people. so with all of us being together and making it feel very safe is challenging, but we are working on it and we are getting there. you're watching san francisco rising with chris manners. special guest is david chu. hi i'm chris manners and you're watching san francisco rising the show that's about restarting rebuilding and re imagining our city. i guess today is david chiu, the city attorney for the city and county of san francisco , and he's here today to talk to

us about the opioid crisis, reproductive rights and the non citizen voting program. mr chu, welcome to the show. thanks for having me on happy to talk about whatever you want me to talk about, so can we start by explaining the difference between the city attorney's office and the district attorney's office? i think it could be slightly confused. that is a very common fusion with members of the public so um, if you get arrested in san francisco by the san francisco police department, all criminal matters are dealt with by the san francisco district attorney . we handle all civil matters on behalf of the city and county of san francisco. what that means is a number of things. we provide advice and counsel to all actors within city government from our mayor. every member of the board of supervisors to the 100 plus departments, commissions boards that represent the city and county of san francisco. we also defend the city against thousands of lawsuits. so if you slip and fall in front of city hall if there's a bus accident

if there is an incident involving the san francisco police department, we defend those matters. we also bring lawsuits on behalf of the city and county of san francisco, where most famous for litigating and obtaining the constitutional right to marry for lgbtq couples have sued gun manufacturers, payday lenders, oil companies, you name it, who are undercutting the rights of san franciscans and the city and county of san francisco. so now moving on to the opioid crisis. i understand you've had some success in court, um, dealing with manufacturers, distributors and pharmacies. could you elaborate a little bit on that for us, so the opioid industry and by that i refer to the legal industry that prescribes pain pills. um over years. uh, deceived americans and resulted in literally thousands upon thousands of deaths and

tragedies that we see on our streets every day when it comes to the addictions that folks are experiencing. many of the addictions really stemmed from what happened over a decade plus period where the prescription pain industry marketed prescription pills in ways that were false. we were one of thousands of jurisdictions around america that brought a lawsuit against the opioid industry. but we've had a particular set of successes that others have not. ah we initially brought a lawsuit a few years ago against every part of the opioid supply chain, and that included manufacturers, distributors and retailers, including pharmacies over the course of four plus years. a number of these corporate defendants settled with us. we've as of this moment brought in over $120 million of cash and services. to the city to help address the root causes of what we're talking about. but a few months ago, we had a really historic verdict against the

pharmacy, walgreens and their role walgreens was responsible for literally over 100 million pills, flooding the streets of san francisco over a period of years where they flouted federal law that require them to track where they're pills were going to. they had a what? what we refer to as a phil phil phil. pharmacy culture where folks would bring in their prescriptions, and the pharmacist would just fill them without checking why someone was coming in multiple times without checking why certain doctors were seen a 100 fold increase in the number of opioid prescriptions that they were prescribing. so we had a historic judgment against walgreens recently, but it's been a very intense lawsuit. and we know that will never bring back the lives that we have lost to opioid addictions. but it's critical for us that we get the resources that we need. maybe one other thing i'll mention because it's often confusion. a

large percentage of folks who are addicted to street level drugs say heroin or fentanyl started their addictions. with painkillers, opioid medications that were prescribed through doctors provided through pharmacies and so literally the suffering that we're seeing on our streets was caused by the opioid industry over many, many years and has created the significant crisis that we are dealing with right now. right right now moving on. i understand after the recent supreme court ruling, striking down robust as wade that you've put together an organization that's designed to help mm. provide free services to people who are both. seeking abortions and providing them can you tell us about the organization? sure so, um, before the dobbs decision came down, but after we learned about the leak from the supreme court about the draft that suggested the decision would be as bad as it has turned out to be, um, i reached out to leadership from the bar association of san francisco

because we knew that if that decision came down there would be tens of thousands of patients around the country as well as providers whose legal situation would be in jeopardy. women doctors, nurses who could be subjected to lawsuits who could be arrested who could be prosecuted, particularly in red states? 26 states where rights are being rolled back or in the process or have already been rolled back because of the dobbs decision. so we put out a call to lawyers all over the bay and frankly, all over the country, and as of this moment there have been over 70 law firms that have answered our call to be part of the legal alliance for reproductive rights who have committed to reviewing cases and providing pro bono assistance to patients and providers who are at legal risk. we also are looking at potential cases that these lawyers can bring against various states. in these areas that are looking to deprive women and patients and providers

of their of their rights. um it is a very dark time in america, and i'm really proud that that barrier attorneys, the legal community care have stepped up to answer the call. it's very important that's great. so now the non citizen voting program that was passed by voters just for school boards has faced them court challenges recently, but it was in place for the most recent election that we've had. how do you see that situation panning out? in fact, it's been in place for now. five school board elections. um so a little bit of background in our san francisco schools over one out of three kids. has a parent who is a non citizen who doesn't have a say in the election of the policy makers that dictate the future of our san francisco public schools, and so over a number of years, there has been a movement to allow immigrant parents to vote in school board elections. few things i'll mention about that is our country has a very long history

when it comes to allowing immigrants to vote. from 17 76 for 100 and 50 years until after world war. one immigrants were allowed to vote in most states in our country on the theory that we want to assimilate immigrants in american democratic values and institutions, and it wasn't until an anti immigrant backlash in world war one that that sort of ended. but in recent years, um cities across america have allowed this to happen. in fact, at this moment, believe there are over a dozen cities that have voted to allow non citizens to vote in a number of context. now, this is particularly important in our schools just given how challenge our schools are, and given that we know that when we engage more parents in her school system, regardless of their citizenship it helps to lift up our schools for all parents. and so in 2016 the voters of san francisco past about measure that allowed this to happen. unfortunately earlier this year, there were

conservative organizations that came to san francisco to bring a lawsuit to try to overturn this , and i should also mention it is obviously the perspective of our office and our city that this is constitutional. nothing in the constitution prohibits non citizens from voting. and in fact, there's an explicit provision in the constitution that allows chartered cities like san francisco when it comes to school board elections to be able to dictate the time and manner of those elections. and so, uh, we are involved in litigation on this issue. there was an initial ruling that was not good for us that essentially said at the trial court level. we shouldn't allow this. um we appealed it up to the appellate level. the appellate court made an initial decision to allow this past november election to proceed as it has for the last previous four elections. we're going to be in front of that court soon. stay tuned. we'll see what happens. it was good to hear that the city was able to

reach a settlement with the center for medicare and medicaid services are meant laguna honda could still operate. how did you manage to reach that agreement? it was not an easy conversation . just a little bit of background. so laguna honda has been an incredibly important institution in san francisco for 150 years, taking care of our most vulnerable patients are frail, very elderly patients, many of whom are at end of life. and a few years ago, there were some issues in that hospital. some violations of rules that we very much want to make sure don't get violated. there were folks that weren't using proper ppe, who are bringing cigarette lighters into the facility, who might have brought some contraband into the facilities. we have zero tolerance for that and have made that very clear. we self reported some of these violations to the federal authorities. and unfortunately from our perspective, they took the very disproportionate step of ordering the closure. the permanent closure of lugano, honda. problematic on a number

of reasons. first and foremost, there are just no skilled nursing facility beds not just in california but around the country. after their order came down. we literally were putting 1000 calls a day to skilled nursing facilities around california and around the country and could find nowhere to move the 700 patients that we had had in the gonna honda but just as disturbingly as we were forced to start moving some of these patients, a number of them died. there's a concept in medicine known as transfer trauma. when you move someone who is that frail and unfortunately, folks folks died and we were at a point where we were five weeks away from the deadline for the federal government. that they had provided to us to close the facility. so uh and we have been trying for months to get the federal government to reconsider their action, so i was compelled to bring a lawsuit on behalf of the city and county of san francisco and very pleased and appreciate that we were able to

come to a settlement whereby transfers will be delayed at least until next year. we're going to have at least a year of funding. to keep the facility open, and hopefully we can get back up on our feet and ensure that no future violations occur because this is an institution that has to stay open for the good of these patients. quite right, quite right. so finally, congratulations on winning an important public power service dispute with pg and e. um why is it important that the city's rights as a local power provider maintained well, so san francisco has been a local power provider for decades. we are fortunate to have access through our hedge hetchy hydroelectric system to provide electricity to a number of providers, particularly public recipients of that. and unfortunately, pg any has used its monopoly when it comes to private electricity to try to stop that, and to block that, and from our perspective, they violated federal law in adding literally

tens of millions of dollars of expenses to san francisco and institutions that we're trying to ensure um, public power infrastructure. put years of delays on our ability to do this, and so we had to bring a number of appeals in the federal commission. ah we were successful in those appeals, and there was a decision recently that basically held the pg and e could not use its monopoly to unfairly delay or add tens of millions of dollars of cost. to the city and county of san francisco, as we are trying to move forward with our vision of public power. clearly pgd has not been able to serve not just san francisco but northern california. well we all know that with the wildfires with its bankruptcies, with all the issues that they've had, we think there is a different model to move forward on and we are grateful to the court. and providing a ruling that allows us to move forward. well thank you so much for coming on the show. i really appreciate the

time you've given us here today. i appreciate and thanks for your thanks for your questions. thank you. well that's it. for this episode, we'll be back with another one shortly for sf gov t v. i'm chris manners. thanks for watching. yeah. >> san francisco is a positive impact on my chinese business. >> i'm the founder of joe-joe. i'm a san francisco based chinese artist. i grew up in the bayview district. i am from china i started at an early age i started at age of 10 my grandfather my biggest inspiration. and i have followed with my traditional art teacher in

china:i host educational workshops at the museum and local library. and i also provide chinese writing in public middle school and that way i hold more people fall in love with the beautiful of our chinese calligraphy. it is a part of our heritage. and so we need to keep this culture alive. hand writing is necessary field that needs to be preserved generation toieneration. this art form is fading away. but since covid i have been very dedicated to this art and i hope that my passions and serving this art form. there are many stores and shopping centers and companies that are interested in chinese

cal iing ravi. i feel motivated to my passion for chinese calligraphy in today's world. so people can always enjoy the beauty of chinese calligraphy, from time to time i have a choice to traditional chinese calligraphy to make it more interesting. we do calligraphy on paper. i can do calligraphy different low. >> my inspiration is from nature and provide calligraphy that was popular style of persons time. i will invite to you check out my website or instagram.

and there is some events and updated upcoming events that you can participate.

jury room good morning. an honor to stands here along side mayor breed. epa administrator fox and epa9 add administrator martha and community lead and president of our citizen advisory committee garcia. if this occasion marks a mile stone in the puc commitment to environmental stewardship, climate change resilience. i want to thank the team usa of the puc this made today a reality and those in the loan agreement to crews working hard on site at