know. not reoffended and. >> right. >> i'm trying to understand are you finding it difficult and challenges for this diversion program for the 340eb8 to make sure that people don't >> yes. so directly (captioning is ending at this point due to the time limit provided for captioning)

for opioid use disorder is the single most studied intervention in and most effective intervention to prevent people from dying from opioid overdoses. it's the most

effective intervention now. people we don't say that you have to do that. people have choices. but to say that a person who is on medication for their addiction is not abstinent is absolutely stigmatizing. and it is very much outside of the realm of mainstream science around substance use disorder and how to address opioid use. we do not say that people who are on medications for their depression are not really working on their depression and that it's only when they go off that medication that they are actually healed. we consider that some people are on medications forever. so i would like to please ask you to consider that people who are on medications or on medicine when they're on medicine, it has nothing to do with whether they're abstinent or not. abstinence is an entirely different set of commitments and behaviors. i just want to

clarify, too. i don't think i've heard anyone say that here today. we've talked about abstinence based recovery, but i don't think anyone here has said that if you are on some medically assisted treatment, you're not an abstinence based recovery. i don't think i heard any of my colleagues say that. i mean, i understand that maybe other people might say that. and that is where there's contention on. but i don't think anyone has said that. i haven't heard that. okay. i think like i think there was a question that was posed about, okay, that's your opioid treatment program. is that are medication based? what about your abstinence programs? and so those those things like shouldn't be in the same sentence. and in my mind, just because it you one can assume that that means that the opioid programs are not actually helping people pursue an abstinence based recovery. they're still you know, people are in abstinence, but you can ask me lots about that later. so in this in this slide, i want to talk about sort of an ideal world. and i want to actually i

want to make the notion even of what this commit, what this hearing is titled treatment on demand. i want us to think differently about what we say is treatment because because i think we're not all saying the same things about what treatment is. so if treatment is opioid treatment programs and if it's residential and outpatient substance use treatment, that is a specific thing. but we consider a lot of points along the way. part of the space that people need to prevent them from dying and to prevent them from being on the street to having a worse outcome for themselves and for the community. so i want to i want to make the notion of treatment, but i think the coalition does like a more complicated, nuanced thing. and what's the most important point in that spectrum is that we place the person at the center and then we create a safety net around them so that we never lose connection with them. we take a lot of people into

treatment. healthright 360 alone has served 14 000 people over the last ten years in san francisco in residential treatment, 14,000. now, as is true of most programs, 50% of those people this is kind of a national average leave treatment prematurely. we they came in, they changed their mind, had a recurrence of drug use. they left. we need to create services that have people connected all the way along the way. and so that's the question we need to be asking ourselves, not do we have enough treatment capacity and treatment beds, which i think we don't, but also what other services are we missing in this continuum. okay. so i'm kind of trying to go fast. sorry so here's the biggest barrier, and i i've talked supervisor madeline, i've presented here

before, like before covid. i think that's the last time i talked here before. and what i said then was staff and i will say this again. a treatment bed is just a piece of furniture. if we don't have staff and i think i speak for the entire community city of treatment providers and service providers and say that staffing is at a crisis s level. and i know you are all sick of hearing that. like at this point, you're like, whatever, i'm sick of saying it. i'm sick of saying it. i have seen colleagues who are younger than me as directors retire because they're just sick of that being the problem. and so we can't provide the service at the capacity that we that we would want to because we don't have staff and that is largely a function of pay. it's a function of pay of what people get paid. if we don't have a pipeline for providers, it's because people

with lived experience actually want a job where they can live like within 30 miles of where they work or 50 miles of where they work. they want a job where they don't have to have three jobs. and so we pay people the rates that that we that we get paid don't allow for any kind of a pay that is at parity with city workers doing the same job. so we ask we plead for parity of pay now we know we don't have pensions for the city worker, for the city workers. do and that's great. we wish we all did. but for all the nonprofit service workers that don't have that, but at the very least, do not assume that we can do the job for less because we can't. and that's that throttles our ability to take clients in in half the time. if we can't take people in, it's because we don't have enough people to be able to do that. and i want you to hear that with a sense of urgency and desperation in, you know, rather

than like when we had to shut down detox intake for a week because of a covid outbreak like that was awful. that was horrible. it was horrible for us. it was horrible for the city . and you know, what i want to hear is like ten years ago, i would have heard you all saying, what can we do? how can we help? and this time, i don't know. we got called for an out for an audit. so we want you to partner with us and recognize that this is a crisis. this is a crisis for everybody here who provides this service. so we agree, as i said earlier, about like who who are we measuring? we agree completely that we do not have an accurate measure of like who needs services, who wants services. and i would say that we continue to offer people we continue to try to offer people services, is that they don't want and we think if we just do more of it, they'll want it. instead of saying, what do

people want? what do people who are using drugs, what do they want and what do they need? and i want to talk. i'll mention briefly los angeles county. we operate in l.a. county as well. the county has an initiative called reaching the 95, and that is that initiative is based on federal data that is collected every year. it's always about two years old on on people who access people seeking treatment. people who access treatment. and this fact is held true for a long time. 95% of the people with substance use disorder are in the country. neither want nor seek treatment. 95. that number is true everywhere and has been the case. so what can we do as a health system and as a city to reach that 95% so they don't get sicker, get worse or die of an overdose? and so l.a county is really kind of framed its response around yes, we're going to provide treatment, but how do we reach the other 95? and i

would urge you to, to consider that talk with some of your colleagues who are down in l.a. because they've done a lot of work around trying to get that kind of information and trying to figure out what are the gaps and what can they provide. so we definitely need to figure out who's not getting services, why they're not getting services and what the services are that people want. and until we do that, we will have insufficient capacity. we our capacity now demands that people either don't get services or they have to tell us they want treatment. they have to say they have to come to treatment, say, i want treatment. and, you know, it is a system in which we're actually asking people to lie in order to get a bed because maybe they don't want treatment. maybe they don't want to stop using drugs. maybe they want to stop using meth, but they don't want to stop using some other drug, but that you start the relationship by not being honest. so we need to figure out what it is, determine what it is that people

want and get them that. and finally, i think we want obviously we need workforce development, we need dollars for training. we have established great relationships, for example , with code tenderloin in terms of trying to move people, you know, trying to create a better pipeline. but without the dollars to pay staff, it's, you know, it's kind of a dead end. um and i think with that, i will take any questions you might have for me. i can answer lots of questions because as you know, we are the we're the main provider of treatment here. i can definitely tell you what it's like to work in the program. i can tell you why people don't come in or get turned away. and i have lots of ideas and thoughts, so i'm here for you. bring it on. thank thank, thank you for the presentation and thank you for

the work that that you do. and that that you're understaffed staff do under understaffed, under compensated. um i mean, to your point, i, you know the point of this hearing is a little bit you know, the i at least from my perspective, my and i think our interest in figuring out what are the gaps, how do we close them and what i you know, i and i think undeniably that i mean you were talking about staffing and staffing is worse. i think i maybe i don't know if i'm making this up, but i think you're healthright 360 and i don't think you're alone. i think you're i think you're missing like 30, 40% of the positions that you would like to have. i think this is a state of california figure, but i have 75 vacancies today in san francisco, mostly client facing services. right that's a lot. and i, i assume that there is

some kind of plea that is made to the city, to the department of public health, to increase compensation to whatever the formula is by which you are. you are compensated to increase that and allow you to pay your employees more and back to my original sort of what i said in the introduction, i mean, the theory of these treatment on demand reports is, is that they inform budgets. and i've yet to see that happen. and partly it's because there's so little actual tangible gaps, analysis going on in these treatment on demand reports like you couldn't figure out from looking at any of the treatment. i mean, the treatment on demand reports are better now than they were when we started these hearings way back then. but they're still not saying we think that to make to actually be able to staff up all the treatment beds that we have paid for that we would need to be compensating the providers by

some additional amount. and we think that to get there, it's probably another $15 million or whatever it would be in the system. and it would be, this isn't for you to answer, i don't think. but i mean, your primary recommendation is workforce development, recruitment and retention. and it's a statewide problem. san francisco. i don't think can solve this on our own, but it does seem like we need to figure out a way to increase the pay for your employees as be bond that are are there things that a municipal government ought to be doing about staffing for the nonprofits that that that provide the a service like this that we are so desperate for? yeah. so i think there's a tendency on public purchasers of service that put things out to bid. this is not unique to san francisco to say hey i'm going to use like a kind of a gross example, like i want to buy 100 units of service and i have

$100. and so, so and so we as providers will say, okay, we're going to try our best to do that, but we really see you didn't really cost out what it cost to actually deliver those 100 units of service. so, you know, we bid on the contract, we get the program, we get it up and running. and lo and behold, we can't actually hire staff because you didn't really cost out what does it actually cost to do that? we didn't do an analysis. and again, this is not unique to san francisco. and so we you know, the providers strive to meet that and don't. and what happens is you have a underpaid workers because you still tried to do it with within the budget constraints assuming 100 units of service. we actually don't end up delivering the so you get like the worst of both worlds. you don't get the 100 units of service because there's no staff and the staff aren't getting paid well. and so and, and you know, you know, even cal, the dcs didn't get it right either. they just did a

whole rate study cauline payments have changed and even they got it wrong in many locations, right? they made errors and they tried to figure out the costing. but i don't think it's impossible. i think you have a really smart controller's office, and i think that they're pretty collaborative. and i think that we could work together to say this is what it costs. again, start with the parity wage. so when you do a budget and say, i want to buy this much services and then you say, assuming and we actually worked with seiu and did a crosswalk of city jobs and they're not titled the same. so we did a crosswalk. and so if you say, okay, these are equivalent to this, this is actually what it's going to cost staff wise to do this. this is so we think we can come up with a realistic expectation then then then you as policy makers have to make a decision whether you want to buy less beds and they're really well, they're well and i'm using beds. this is all kinds of services. whether you want to buy, you're willing to say, i'm going to buy less services, but i'm really going to pay fully for them. so

they're fully delivered and we're not burning staff out or we're just going to get we're going to allocate more money to this so we can truly do the things we need to do. so i do think it's not impossible rebel, but it is kind of starts from the premise of where your aspirational and what you want but you don't actually know what it costs to do that right? so, you know, i think i think we're we've already seen some challenges with some of some of our nonprofits actually collapsing under the load. and i expect that in coming years we may well see more of that. so yes, statewide can can i just interject on that point in terms of like so when we're asking for 100 units of service, i'm just using that as an example because that's what you said. do you then come back to the city and say, i can't give you 100 units of service because i'm only a staff to give you 35? or do you take the contract for 100 units of service and get paid on 100 units of service and then tell us then after we've entered into a contract with you that you can't do it. so the contracting

process, you're you're typically going to say, well, you tell them, i'm not sure i can do that. and but this is all the money we have. i'm not going to say i'm not going to try my best to do what you're asking me to do because we want people to get served. so at the end, we don't say, i refuse. most of the time in some in some place, not in san francisco, but in some places we've gone like we just can't we're not going to do that. that's like ridiculous. but in most places we're going to like, we try to negotiate out on that. but at the end of the day, it is a finite amount of money. it's a finite pool of dollars and believe me, medi-cal , i just want to say medi-cal has really as much as it's a pain in the butt and it's bureaucratic medical cal is enabled by the city to have san francisco to have the most robust kind of residential step down bridge housing of any county that we in the state because because you have redeployed general fund dollars that used to buy treatment or. i

used to be here. look, i've been here, i've been before this body and the health commission year over year before medi-cal begging for our dollars for next year. so that doesn't happen as much because of medi-cal. but, but nevertheless, it's still a finite pool of money. you know, it may pay sometimes $0.90 on the dollar, but, you know, we are all aspirationally trying to do the same thing without costing it out. okay. i just want to make sure. so when you're responding and entering into contract with the city and county, county of san francisco, you are telling them, i can't i can't really give you what you want, but aspirationally i will try. i i'll do my best. was that is that is a contract negotiation between you as a nonprofit and the city and county of san francisco that you can't really meet what they're asking for in the rfp but you're going to try with the limited staff you have that is a contracting. that's the nature of contracting. yes yes. okay. that's very interesting. yeah, that is a nature of contracting. they will do our best that maybe

maybe we're maybe some people will come into the field. we didn't expect. maybe something will happen. but we're going to try to provide the service. there was a period of time where we actually gave raises to staff because we couldn't fill. it was like desperate. we couldn't operate programs. we gave raises. if we had filled every position with those raises, we would have actually blown the contract like we were willing, meaning we would have we would have blown the contract max halfway through the year. and i would have i would have been one of those program arms that you were calling up here going, how could you have done that? like vitka, that was so irresponsible . do you understand that? so something as life and death. yes. as the detox center, especially detox from alcohol detoxing from opiate, some thing that my mind is a little bit blown right now, to be honest. the fact i'm glad actually. well, i mean, i'm glad because you're hearing it. no, no, i just i'm having a problem knowing that if we're entering into a contract for what i think

are life and death services for detox withdrawal from drugs and we're in a like a contracting situation with the city and county of san francisco to enter into contract where we kind of say we'll see what happens. i mean, that's that's alarming to me because people are being turned away and people could die. and this is this is a substance, a substance abuse disorder is a disease that kills . we are seeing it over and over and over again every day on our streets. and if we are in if the city and county of san francisco is so lackadaisically entering into contract saying we want this many services, maybe you can provide it, maybe you can't, we'll see what happens. we do know that detox is of vital nature to get people off drugs. i mean, it's just that's alarming to me. and to follow up on that, i'm just wondering how many empty detox beds do we have right now? um, probably. seven on on any given morning for health, right. i can't speak for

i know that harbor lights has a detox. we have a medically supported detox as well as a social detox. and on any given morning, there's about. ten between 8 and 10 beds available in the morning. sometimes more will become available midday because people leave treatment. but about that in the morning we would and i will tell you, just in terms of fiscal capacity, honestly, we would be 100% full health rate would be and that's hundreds. it's a couple hundred beds of treatment beds, including withdrawal management would be full. were we fully staffed. i also want to acknowledge that budgeting for city services is done exactly the same in every department, and all those services are complimentary to what we offer in treatment. so permanent supportive housing, wraparound services, all of those things. it's part of a system. so it's, you know, it's health department , it's every department that purchases services has a limited

amount of dollars and doesn't say you tell us what you think it costs. we'll pay you that no department does that. that's a i mean that's a that's a fact. that's why we have to change our whole contracting process. but that's for another day. all right. thank you. um. all right. so i wanted to ask about the. the step down. the gap on step down, because you have you have, i think, been one of, if not the major, if not the major provider, one of the major providers of step down facilities for people who are coming out of a treatment. there's others here positive direction and salvation army. so one of the things that is not in these treatment on demand reports yet although i think it might be a good thing to have is some kind of effort to measure the if there's unmet need for step down facilities for people

coming out of coming out of treatment. i don't know if you have a sense of what that i have like a like a back of the envelope sense which is probably not what you want, but i can like i've said this, the back in the envelope. yeah, i've said this since the beginning of drug medi-cal. so assume ing that the average length of stay in substance use treatment is 90 days and assuming that the average length of stay for a funded residential step down is 1 to 2 years, which is kind of what it needs to be. and by the way, that's a great system of care if you have all of it and it's functioning same day access. it's a great system of care. you know, people don't necessarily need intensive residential treatment for, you know, a year is what they do need is a closely tied system of care where they have safe, supportive housing and step downs and intensive outpatient outpatient services and medication. et cetera. so back of the envelope, i would say you

need three times the number of step down beds as you do treatment beds. if you just think of it as a turnover right, your turn. let's say everybody stays in treatment and you turn treatment over four times a year. but you only. but. but you only turn at best. you turn the step down population over once a year. so and then assuming there's drop outs in between, at best, right. like it's three, three x and we have far less than that. right. i think we have, we have a fraction. yeah i think we have what, 300 something treatment beds in the city probably. and i do not think we have 900. yeah. step down beds. okay and then i guess i asked this. i asked dr. kunze this question of how important is it? i mean, you talked about you wanted to sort of describe a continuum of care that we ought to be building out and meeting people in lots of places along the way and a little bit of a redefinition of treatment on demand. but for good old un

redefined treatment on demand, the idea was is there's some set of people who have these moments of where they actually think they want to stop using. and i actually think the policymakers are mostly agnostic on i don't think there's a bunch of us who are on a crusade to kill medication assisted. i don't think anybody up here is trying to kill medication assisted treatment. but but in general, all we want to take advantage of advantage of those moments where someone is saying, yes, i would happily start taking buprenorphine or i or or or for whatever reason, i don't want or i'm a meth user and there's nothing for me except you know, a program that is not medication assisted. so the treatment on demand framework suggests that that's a really we ought to be spending a fair amount of time, energy and effort on having a way to catch those people in those moments and not let not let go of them. and i'm curious for you, as someone who's been in this space for a long, long

time, is that correct? i mean, should we be focusing or or are we is that not the right focus? it's the right focus is not the only focus. okay. so the experience of people who are seeking treatment in terms of experience of people is variable like today i want to be in treatment. i can't do this anymore. and you want that person in in this in this service that they're seeking at that very moment. we 100 i think we all completely agree on that. and that can be difficult to do. it seems like we're far away from that right now in san francisco. yeah, we are somewhat. i mean, so we do take in a bunch of people in withdrawal management. withdrawal management is appropriate. we believe is an appropriate level of care for anybody coming in off the street unless they were just using maybe like cannabis. and that's why they're seeking treatment. so it's an appropriate level

because it's a higher level of monitor and supervision that's very easy to get into. the challenges to that are sometimes literally not having enough staff check this out. wait a minute. and a person has to wait six hours in a waiting room to be seen. a person who is waiting six hours in a waiting room just to process their intake and get you know, put on a van and sent to the treatment. it seems like a lot of time to get up and leave. it's a hell of a lot of time to get up and leave right? so just that's kind of the universe of treatment. so it sort of seems like anything beyond 20 minutes, you're you're failing. and so whether it's a day or five days or, you know, all of these numbers we have, we kind of need it to be like like now. and that's not i'm not saying this is a health right problem. i mean, i think you would happily, if the city gave you funding and staff and all the things you needed, you would run a 24 over seven intake, presumably for 100. happy to do it. happy to do it. we're not

doing that with you right now. and we're not even identifying it in our in our treatment on demand reports is the thing that we ought to be doing right. i mean, i do think there's like because we do look at our data really closely and i do think there's things we could do, like a little changes to the system that makes it more pleasant for people to stay longer hours. yeah like we literally raised money to move the waiting room to the fourth floor because on the first floor, like, this is how we think, right? it's easier to walk out. you literally looking out the front door right? and you see the busses going by and maybe you see some friends go by or whatever, move it to the fourth floor, make sure they have some food. i mean, i do think we think on a very we have to think both grand and granular in how we respond. okay. all right. that's all i got. that's it. thank you. thank you. treatment on demand coalition. thank you. and sir, slide. next up, we have the recovery coalition. yes.

hello. good afternoon, supervisors. while we're getting our presentation ready, i'd just like to introduce myself. my name is steve adami. i'm the executive director of the way out, former director of the adult probation department's reentry division. and i am joined today by about 70 people from our coalition in san francisco, ranging from city employees, people that run programs, people that have been embed did in this fight in the community for years as before we start, it's really difficult to have a conversation about treatment on demand without including the broader context of what's happening on our streets in san francisco. each year, 19,000 people are cycling in and out of homelessness. on any

given night, 8000 people that don't have a place to call home, 4000 of them are living on our streets. 70% of them are addicted to drugs. there's one detox bed for every 100 homeless people struggling with addiction in our city has been negatively impacted by open air drug markets and public drug use. in 2020, this coalition put forth a platform of recommendations as supervisor stephanie took those recommendations to a hearing in february of 2021. and from that hearing, we've implemented five programs that are serving close to 200 people a day. lisa, you can pull up the slides as i'm always grateful for all the data that's presented and but often mindful behind every statistic is a human life suffering. our coalition has been at the forefront of advancing programs that promote recovery, advance independence and inspire change.

let's go to the next slide. oh, back. stay there. right there. that's fine. san francisco's homeless and addiction crisis is impacting everyone. these headlines are not from conservative news outlets or tech billionaire hours. they're from our own publication expressing not just incendiary political views or the perspectives of tax billionaires, but the views of concerned residents. clearly something is broken, not just the political symbolism. next slide. last month, we had a memorial for people that we've lost to addiction and the supervisor mandelman, so rightly says that it's easier to get high into difficult to get into treatment in san francisco. so one thing we don't talk about that is why the bureaucratic hurdles to get people into treatment, mostly driven by medi-cal. we believe that people access knowing or desiring services should have direct

access to providers of services and often in respectfully, public health gets in the way. if you're homeless on sixth street shooting heroin, you have to go to 1380 howard street and sign up for an assessment. from that assessment, they'll give you a level of care determination, at which point then you can get on a list to either go to withdrawal management or residential treatment. we believe that people that want services should be able to go directly to providers and have access to services. next slide. and so none of this happens in a vacuum as we talk about treatment on demand, we have to acknowledge what's happening on our streets, the impact of open air drug scenes. i don't need to preach about it. i know that everyone in this room sees it with their own eyes. but i'm here to emphasize, guys, that this is affecting everyone and you know, from users. we've lost over 3000 people. we're distributing

syringes in an effort to save lives. we're upped our up, our narcan distribution, and yet we continue to see a treatment decline. our community fills unsafe. they feel exposed. this is traumatic to walk by every day. we need to do something about that. and this is having impact on our businesses and, you know, again, i don't need to talk about the economic impact. this is having to our city. and then there's the faith and distrust that's that's growing amongst community members with our government. this idea that there's been a lot of inaction. right? we've seen a lot of solutions. we heard from a lot of departments today and yet we don't see a culture that embraces, acknowledge, acknowledging, failure and saying, hey, we're going to do something differently. and the only we i think, individuals

that seem to be thriving and i know that this has been changing lately with the addition of demak, but users seem to be the only ones who seem to be benefiting, benefiting from this whole situation. this culture of inaction and, you know, we heard recently from the papers that 535 individuals who had been released from from the jails waiting for drug drug sales had been released. and who are failed to appear in court. so we have something that's really broken in our system that's creating this culture and making treatment seekers. as as you heard from the fire department, just not being demand. next slide. and just to again highlight our and i don't want to pick on the homeless population. i mean this is really we can have if we had the data we can talk about drug users who are using inside and

within their homes. but just to kind of just to call out the obvious that this is not normal. san francisco's what we see on our streets is not at all normal. we have a chronically homeless population at nearly 10. the national average. we have more than double the national average of chronic of chronic, of homelessness, homeless people experiencing homelessness who are addicts and again, our treatment admissions are declining. next slide. so this is a great depiction of one way people walk through care to get better and likely one of the most logical ways. and what we see in san francisco is that people who are using drugs problematically, it's a choice. they use them for a reason and they need to get help. and there's a lot of different ways to help people. but i think one

of the things that we're we're really thinking about is like how to get people to a place where they're no longer using drugs and one of those ways is to help people stabilize and heal by giving them real time access to withdrawal management or detox and then rapidly transitioning them to long term residential care where they begin to learn how to live after residential treatment. they would go to a step down facility or transitional housing where they begin practicing living and become financial independent, where then they can reclaim their place in the community and be independent. and what we typically see in san francisco there was a question earlier about from the fire department mentioned that, you know, nobody wanted to go to treatment. well, if you're shooting dope on the streets and they offer you an apartment or treatment, i don't know one drug addict that's going to choose treatment. i'm always choosing a free apartment. and there are interception points at tom is going to talk about next. but what we see in san francisco is

people go from being addicted to drugs, straight to step four, and then we wonder why 70% of the odd deaths happened inside. we wonder why the people that get put inside don't want to stay inside and they want to hang out with their friends in the community, which makes sense. but i just think the culture in san francisco needs to shift and we need to start talking about the impact. drugs are having on everyone, especially those who are using them. i mean, getting people to not die is a great first step, but it can't be the last step. i don't always agree that people that are using drugs know what's best for them. when i got out of prison, people asked me, well, hey, what do you want to do? and i said, i have no idea what i want to do. i've been shooting dope and breaking the law for 20 years. i need somebody to tell me what to do. i'm trying to get to a place where my life becomes better. and i think the folks you're going to hear from after me have created this culture in san francisco amongst several programs. and i just think we

need to start listening to the broader community and enlarge the solution space to incorporate more opportunities for people that are struggling. thank you. next slide, please. hi, good afternoon, supervisors. tom wolf, recovery advocate. i just want to talk to you a little bit about the impacts of public policy. and as the fire department had mentioned earlier, the washing machine that people get caught up in out on the street. and so here you see this example of a homeless someone who's homeless, struggling with addiction, comes to the tenderloin, open air market from a variety of different reasons. they're provided with, you know, harm reduction tools such as a tent, food, clean drug paraphernalia, enabling them to stay out there on the street because no one's coming out there and bothering them. so think of it this way. if you have a tent, you're struggling with fentanyl addiction. there's 12 drug dealers on the corner there selling fentanyl for five bucks. and nobody's bothering you. why would you stop? you really have

to think of it that way. because that's the way i thought of it when i was out on the street. then, of course, you have to support your addiction. you see, number three, you can steal goods under $950, which talks about the intersectionality between homelessness, criminal justice reform and drug policy in our state, in our city. the interruption opportunities, an individual odds or faces other medical emergency and is brought to the hospital for treatment. i've reversed the guys on willow a couple of months ago. the ambulance came, took him away. three hours later, he was back on willow using fentanyl. so that intervention opportunity doesn't work. and you can see it goes to from the e.r. to the or jail. the individual is sent to a detox bed, potentially, or they're just given a slip to come back in 1 to 3 days to access it. or they can just say, forget it. i want to go and they go. so the other interrupt an opportunity is an individual is intervened upon because they're committing crimes to support their addiction out on the street. however, given the low consequence chances for crime or

drug use and the infrequency of arrests, the efficacy of this interruption point is diminishing. i think destiny pointed out, made a really good point, that there are 535 organized drug dealers that were arrested and released out either on pretrial diversion or just released on their own recognizance pending, pending hearing that did not show up for their court hearings that have open bench warrants out in san francisco right now. i think earlier there was a piece of data, a few months ago in san francisco when the police started doing sweeps on the street. 25% of those that were arrested for using drugs actually had open warrants. and other counties where they had come to san francisco to abscond from their obligations to the law and the county that they were in. these are this data, this is not just i'm not making this up. this is all truth, folks. okay and without anywhere else to go during the wait period, the individual returns to the streets and back to square one, which is the washing machine that we're talking about. next slide, please. so just real quickly, drug addiction is a progressive disorder that ends in death. i'll just put it this way. so

fentanyl has changed the game. it's changed the game on our streets. it's changed the game in our permanent supportive housing. with all the overdose deaths happening inside, it's 10 to 100 times stronger than morphine or heroin. in most cases, it's unregulated. right we all admit that it's toxic. that whole thing is mixed with xylazine now. and tranq and all that stuff you're starting to see show up. and so the window of opportunity to intervene for that individual has shrunk. it has gone from maybe, you know, you could go 6 to 8 hours between dosing heroin to you've got to use fentanyl every two hours. now on the street. so your ability to intervene as an outreach worker is very small because the guy uses it, nods out for 45 minutes. he's awake for 30 minutes, and then he's got to use again. so your window to intervene or for the person struggling with addiction, their window to have that moment of clarity has gone from this to this. thank you. the next one.

so i'm here today in support of this. and the thing i want to talk about is if you look at that slide, you show that slide up there. so what's really concerning to me is the death rates from this poison that's in the streets for african-americans. for every 100,315 are dying from this for every 100,000 for hispanics. it's like 80 whites is 70. but what i'm looking at is the amount of people that are dying from this drug that we keep saying we're overwhelmed and i don't understand where the overwhelm is at when we have to address this. this needs to be dealt with. and we can't have it both ways. and i'm a firm believer that accountability and consequence is where compassion

and empathy come from. yeah it's not the other way around because i feel like if you just using compassion and empathy, you're enabling and you're not addressing the problem and the problem is that people are making money and people are dying. and the people that i'm looking at dying are people of color. they're looking at my family that's dying me, that's dying. and i have a really, really hard time address this. so i'm going to always fight for abstinence based treatment. i'm always going to fight for us holding our community accountable. so i'm going to fight for whatever it takes for us to address this problem. and we have to quit ignoring it and saying it's just people getting high because this is a little bit more than that. that stuff is poison and it's killing people. so thank you. real quick , through the chair, if i may request that speakers name for the record. oh, craig johnson. craig johnson. thank you. all right. good afternoon. so we

going to recommendations now our recommendations are simple as this revised san francisco's public health policies to be more inclusive of options that address the needs of all san franciscans, including abstinence based treatment, faith based and culturally specific programs. but i do have to go back to the one in it's inclusive in this one where we're talking about gaps, the gaps are that faith based programs cannot be funded by the city and county of san francisco. the mom and pop programs that help every day with people dealing with their daily stresses of life. do not get any funding and the issue i have with this is that when you look at that, if 3% of the population from san francisco is african american and we have that many number of deaths, how does the department of public health, how does the city and

county of san francisco going to tell us in our community how to help our own people? that's what i have a problem with. and we should be inclusive of in anything that goes on in our community. we should be the ones that are the experts at what happens in our community because as our children, that are dying, it's our kin folks that are dying and that shouldn't happen. and even with like i said, black and brown are the most ones. but when it's us, it's not like it's a big concern. and that's the problem that i have with that one. so therefore, you're talking about a gap that's a huge gap because we don't have those services available for that population. the other one is equal investment for recovery and residential treatment options. as in this city, you were talking about a gap again, the gap is that, yes, harm reduction, all of the passing out needles, all of that is well and good. but there's no balance with it. people are told that i

can give you a needle to use, but how many people are told that there is help for you? what is it that you need besides the needle? besides a having a something to rinse? what is that stuff? pipes and all, whatever it is. but it's just like narcan and giving people narcan good and fine. i'm not knocking that, but it should be more options because if you limit people to those options, you keeping them ghetto dies. the next thing is wage parity between government employees and non profit staff. now this one really hurt me because we had two employees and one was falling asleep all the time. and when finally found out that this person was sleeping in their car, worked two jobs, sleeping in their car and living in this city, now, not only are we doing a disservice s to the people we serve, but we're doing

a disservice to the employees also, the wages need to come up and be comparable to the city. prices for employment. that's the bottom line and i think it's a consensus with everybody in this room. and then the other detriment to this is we take people sometimes formerly recovered. we take them too soon because 90 days of treatment. on my point is not enough time. and after 90 days, you're going to put them in the work back and work in another environment where they're getting exposed and the trauma again, to seeing the same thing that they just trying to get over themselves makes no sense. and that's what i see from the tenderloin. when you bring urban alchemy, not knocking urban alchemy, but you taking brothers that went to the penitentiary for life sentences, got put out the penitentiary because is the government don't want to pay for their medical issues put them on the streets and they turn into the police for the same people that they are are in the same people that

went to prison for. it makes no sense. and that's again, that's a disservice. and mostly what i see people of color, the next one is every city funded outreach team should include a recovery advocate and all team members should be trained on how to connect people to treatment. right now i do know that dpi does send out peers, but again, what they don't talk about a lot of times is that have you ever thought about being sober? it's the conversation you have. it's the connection that you make. i agree with a lot of people that you do have to make a connection with people, but it's also accountability. have so many people tell me all the time, you can't arrest a poor drug addict, but one thing i know because as a drug addict, what i did every day, i had to steal every day in order to support my habit. and i don't think that's changed too much. so it's not necessarily that you're doing something to the poor drug addict, but you got to be accountable for our

stores closing. you have to be accountable to the people that's trying to have a business and put their children through school. we have to be accountable in those areas. and what again, that we have to work together instead of working apart the next one let me because we ain't got that much fun of stabilization center pretreatment program. the other missing piece, a stabilization center where we have a medical treatment on hand, where we have a bed available for a person, where we have food, where we have everything for them to be able to come to. my whole idea of this is that was simple. let a person come in, don't even have to do any paperwork. we embrace you at that moment. would you like to take a shower? would you like to get something to eat? lay down and rest for a minute. whatever it takes for you. maybe 2 or 3 days. then we talk to you and decide about what you want to do. the thing is, some people may decide, i want to keep going back out and getting high, but the fact of

the matter is they know where to come from now on without a referral, without having to go through all of this paperwork to be able to come in. and then if they do want help, then we can do the paperwork and start the paperwork at that point. but the fact of the matter is, is it's like somebody had said earlier, having a huge sign saying help is here. i can't see the next one. what's the next one? okay remove all barriers to drug treatment. those seeking treatment should have direct access to all city funded service. is there basically the same thing? so we can move on that one fully fund drug treatment on demand? we all said that today. and the last one is fund a therapeutic community in the jail to begin to teach people how to live and connect clients to community programs and what we're seeing now is do i necessarily like jails? no, but do we have alternatives in

place? no. so therefore, if people go to jail, we should have more programs in the jail so that not only teach you about how not to use drugs and alcohol , but also teach you how to live when you come out and you know, a lot of times they use the word loosely about rehabilitation. but today it's about her ability action, because today, even if people did know how to live before, something about this fentanyl is poison, makes you forget everything that you've ever known. and sometimes it just needs the skills to be able to taught that and have a proper transition from the jails and coming out to the system. but i just want to thank you guys today for putting up with all of this. you earn your keep today. thank you. thank you. the end, the end. not the end. well, no, no, i mean the end of this

presentation. we're done. just a quick question about the stabilization center. this is something that was mentioned. i don't know. first of all, thank you, cedric. love that. just wondering what you mean by the stable. is it what do you envision the stabilize ation center to look like? and what would it do? we presented this tuesday at the sf next initiative and what we're finding is that the current shelter system, which includes navigation centers, isn't meeting the primary health and behavioral health needs of people on the streets. in a subsequent presentation on yesterday on government accountability data was released that 80% of people that enter our shelter systems return to the streets. you've got to ask yourself what's going on with the people that don't have anywhere to live? and one of the problems is there was a statewide study that was done by ucsf that was released earlier in the summer, 60% of the people have at least one chronic illness, 28% have two or more.

15% had a stroke within the prior six months. it goes on and on and on. the people living on our streets, these are seriously unhealthy and have behavioral health issues. so a stabilization center could ordinates their care. there's no referral system. people could be dropped off or picked up or just knock on the door. they'd come in. they'd get an assessment, both physically and for behavioral health issues. there would be on site clinicians and nurse practitioners. they would stay anywhere from 30 to 90 days and get stabilized and then triaged to the next level of appropriate, appropriate level of care. it's going to be in the chronicle this week. the most important part of it is the cost was $202 per day with all this medical staff included a master lease for a 75 unit building, 7000ft!s of community space, and the shelter's cost around $200 a day. so not only is it cheap, it sounds like it's going to be more effective and could be a little more supportive. the goal of the shelter should not be to return somebody to the streets.

it should be to get people to the next place in their life. and it could be a variety of different places, but it's a need that's not being met currently. and mostly driven by the improper staffing to meet the needs of those people. and we currently i mean, what we did get out of this from the last time we met with you was the billie holiday center, which is it's only a 30 bed facility. she stays full and we get so many calls from the hospitals. when a fire person was talking about that. and also, emt want to bring people there. but we just we stay full. and this was just something that was avoided in the city that we didn't have. now, we would love to have medical staff on hand to be able to because that's something else that doesn't get addressed when people come in. i hear everybody talking about the drugs, the care of the person, but nobody talks about that. the cuts, the abscesses is when the last time you've been to a doctor, do you

have high blood pressure? any of those things? you know, because the focus is always on something else. but the stabilization center, because heard used that today. and it was funny because when i said it the first time, nobody was saying, no, we're not doing that. nobody wanted to have it. now everybody's using the terminology, the stabilization center. this should be instead of having those what them things is where they can go use that at them. hubs should have stabilized centers in every neighborhood. it makes more sense to me and it's using your money more wisely. if you're talking about you really care about people because a hub to me is just like a mortuary. good all right. thank you. it's it strikes me i mean, the stabilization center you all are talking about reminds me a lot of the mental

health services center that that supervisor ronen was envisioned going in mental health sf and the idea of having a 24 over seven facility where people with behavioral health needs would come and then kind of get navigated to the right place, um, was a need then seems like it's still a need. it also we have heard from fire and others that having a place to take people who are seeking treatment but cannot be gotten into the right program or facility in that moment. but that will still be a welcoming place that will keep those folks, you know, seems like a real need. so um, i don't know, fx and others, i think, need to think about what we're doing on the front end for people who may be having those moments of willingness to engage in in treatment and who we are currently losing. i think so. so thanks for your work. thanks for

your presentation. all right. last but not least, the very, very, very patient, trent rhorer . we asked. i don't think we've had hsa participate in these hearings in the past, but it seemed like it made sense because if the mayor and some of us have our way, they're going to be a whole lot more people seeking treatment out sometime after march. and i think there's an open question about whether whether and how we're going to be able to meet that treatment need. and so i thought we would give director rohrer an opportunity to talk a little bit about his preliminary thinking on this. well, at least i got a lot of work done over there. good afternoon. now, supervisors trent rhorer, executive director

of the human services agency. and i just got to say, as you teed it up, supervisor mandelman , we haven't. hsa has not been part of these discussions nor are we immersed in the treatment yet. so cool. it's up the treatment system other than we provide benefits and supports to many people who are suffering from addiction and you know, steve and tom and craig and said cedric, like i said, i'm not in this hsa has not been part of this. but you strike me as as for breaths of fresh air and are telling it like it is, which is fentanyl is different. you know, i've been doing this work for two and a half decades and i think we can all agree this is by far the worst and most dangerous drug epidemic ever. facing hrsa's clients. and when we were chewing on this this initiative about 3 or 4 months ago, we really decided that that

not changing the way that we're giving cash to people who are addicted is not fulfilling. hrsa's mission of improving the well being of people. in fact, it's doing the opposite. it's killing people. so we put this together. i'm going to present on what it is today, really of the mind of we're no longer going to be using taxpayer dollars to provide to people who are addicted, who then use it to kill themselves. and in fact, we think that we can design a system that will help incentivize people to get into the treatment, that will help improve their lives. so on october 17th, the mayor introduced this initiative to go on the ballot in march. it's loosely called the substance use screening, evaluation and treatment initiative. and it's very straightforward. despite what you may have read in many media outlets, it really does the following. it says that if you have a substance use disorder that's related to the use of illegal drugs, you must engage in screening, assessment and treatment in order to continue to receive cash assistance from the city. that's

all it says. i'm i'm a one man show today, so just real quick, just to just to set the stage of who we're talking about, because there's been a lot of discussion in the press about families and taking away money from senior citizens. no, it's not. it's the county adult assistance program or cap is for single adults who have no children under the age of 18. and there's about about 5300 people on cap at any point in time, about 20% of whom are homeless. and about 30% of whom were formerly homeless, and who we successfully placed in permanent supportive housing, largely through care, not cash. so we're talking about 50% of people who are homeless or formerly homeless who are getting capped. about 20% of we do right now, currently, prior to the initiative, we assess everybody who comes through our doors for employability or disability. part of that assessment, we ask about substance use, about 20% of folks disclose the substance use issue during those initial

during the assessment that we currently do. we did some data matches. we matched with the medical examiner and we saw that over over a 12 month period, about 13% of total cap clients had overdosed and died. the recent step up in enforcement through the through the mayor's initiative, about 20 a little over 20% of the total arrests are people who are on public assistance. so clearly there's an overlap and it's not a surprise to me. so the next slide. oh, thanks, cedric. this describes the initiative. the purpose, as i said at the beginning, it's really to engage people who are addicted to illegal drugs with a range of treatment options to support their improved health and life outcomes. so how will it work within the bowels of the human services agency, cap clients who are this is echoing or mirroring state law, which allows counties to require screening for people who are, quote, reasonably believed to be dependent on illegal drugs. they go through.

they currently everyone goes through initial assessment for employability. they would go through a further screening for substance use disorder assessment intervention, and then treatment should should that screening be done by a professional clinician to indicate that they need that they need treatment? important to know that all cap recipients are now are required to do an activity, whether it's workfare, job training, applying for ssi. they need to do something in exchange for their benefits. all this initiative does is add an element, an activity that they're required to do. if someone is not addicted, they do work. if they don't show up to their job training or their work assignment, they lose their cash aid. someone's referred to treatment and they don't show up at treatment and they're blowing it off. they lose their cash. that's what the initiative does. so i just want i wanted to put up a slide. go ahead, said yeah. what this does not because a lot of again in the media and other

and even some of your colleagues folks in the community are characterizing this initiative as something that is absolutely not. it is not a drug testing initiative in fact, it violates state law to condition receipt of public entitlement benefits on a drug test. we simply cannot do it. we aren't doing it. and frankly, we don't want to do it. what we are doing is screening and there are a number of them. i'm learning more and more about this field, so i'm broadening my horizons. there are a lot of screening tools that have have proven effective at determining whether someone is addicted to an illegal drug. in this case, opioids being the largest number of folks we anticipate or expect either contracting with clinicians to do this or partnering with the department of public health or even developing and hiring staff internal to hsa to conduct these screenings. the policies specific to single adults with no kids. it does not apply to our families who are receiving public assistance nor seniors who are on public assistance. we are not requiring sobriety now.

now, recovery is our goal again, i'm teetering on dangerous ground here because i'm not an expert in the in the area of substance abuse treatment. but i don't believe that harm reduction works with a drug like fentanyl that is so deadly, so accessible and so cheap. i might be wrong and i'm open to dialog with my colleagues in the field. i don't believe it works. i think we need to move towards recovery. the drug is to be dangerous and then the fourth bullet cap, it's not an immediate discontinuance. we know people cycle in and out of treatment. if you are making a good faith effort, if you are showing satisfactory participation, you are allowed to fail. you will not lose your cash grant. but if you willfully you can go to the next slide. now, if you willfully say, no, i'm not interested, i'm not going, i don't want to be screened, then you will. no longer receive your your cash. we did not want to increase homelessness as a result of

people losing their cash grants. so what we what the initiative says in the corpus of the of the proposed law that hsa will provide will directly pay a client's landlord, a client who is discontinued. we will directly pay the landlord for at least 30 days with the flexibility to do more if it shows that a lack of payment of rent or no alternative payment of rent will result in homelessness. further, if someone is in city funded permanent supportive housing currently 30% of the cash grant goes directly to hsa to go to the provider. we will continue that for the clients who are discontinued. and so there is no increased homelessness and no operating budget holes in the hsa and their provider budget. there's a poison pill. if we can't develop a treatment system or have treatment slots for people, they won't lose their cash. it's on us. the state law is very clear. the county shall provide the treatment. it shall be free to the client and no grant reduction can occur. if it's not there. we also wanted

to do something else in that we know people will based. i've learned a lot this morning. you know the number of people who accept treatment and the percentage of treatment acceptance is very low. we know people will lose their cash benefits because they're going to say, i don't want it. rather than that savings going to reverting to the general fund, we're going to we have established a treatment fund. so those savings are basically not paying cash grants to people anymore who are addicted. those savings will go to a fund that will help pay for the treatment for those people who do want to go to treatment. so we're not going to take money out of our budget and then the last slide. thanks cedric. really appreciate it. um, just sort of implementation planning. as i said, hsa is new to this. i'm, you know, going in eyes wide open that we need to learn a lot . and part of that process we've already been in discussion, my staff with dr. coons, i've been in discussions with some providers intend to do more of both. we need to identify the potential population. we need to

identify of the current cap recipients who's already in the substance abuse treatment system that's funded by dpa. there is certainly an overlap. try to get a sort of sense on what the demand will be. i would argue i'm not increasing. so we've talked a lot about demand today. this initiative doesn't increase the number of people who need treatment. we're providing cash to people who need treatment. so there's no more people out there who are who are knocking on the treatment door. it's the same people. it's just i believe, of a way to move that needle from a 5% acceptance of treatment or whatever. the number is in the field, higher because we have direct interactions with someone who's sitting across from a caseworker or a clinician saying, i, you know, i'm filling out these forms, i'm talking to you because i need cash assistance to pay my rent. when you develop those relationships in that point in time, you say, oh, by the way, we have a treatment bed for you now, not five days from now. now now. and we have a county, we have about

20 city cars in the parking lot, one of which can take you down the street to health ride, if that's where we're going on mission or wherever else. and we can go now that maybe we'll have a little bit more impact, a little bit better effect. i do know that when i was back, back in the early 2000, when i was helping oversee homelessness or overseeing homelessness, and we developed some outreach teams that had dedicated treatment slots or dedicated shelter beds. and you could offer it right there on the street that there was a much higher uptake than and let me give you a referral and you can go ahead and look for yourself. if so, i would look forward to working with many of the folks who are behind me and the range of treatment providers in the city, as well as to make sure that this initiative should it pass, be one that does move the needle on on the fentanyl epidemic. thank you, director rohrer. i guess maybe to put put the to put sort

of restate the question, i, i have been having about this. given that fx has struggled, seems to be struggling so much to have treatment available for or well to have detox available. well to have treatment for the criminal justice involved population we heard about there's many different population and it and it does not seem like we are meeting treatment on demand and we are talking about expanding the demand by quite a lot. you know, hundreds is probably maybe a thousand. and you don't have to figure this out until january of 2025. but and that's only if it passes. but but what before then? i see where you're going. supervisor so i'm not sure i agree. we need a thousand additional slots right? we know

uptake rate is low. i think we can titrate up. i think we will learn that the beauty of the poison pill is if we somehow magically get 500 people on january 2nd of 2025 saying, i want treatment, what a wonderful thing that would be. and we'll say, okay, we know what the demand is, right? you're not you're not going to lose your grant because you'll get me. but the fact that you want it, great. that's not going to happen. so we will titrate up. but what i'm envisioning is developing a helping to develop and fund, add a treatment system and whether that is a segment of the current system or a brand new set of slots, whether it and slot is to be defined, that is ours. right? we're all a city family, ours being hsa, meaning we're funding it. we're we're overseeing the contracts, we're funding the contract. it's at the level of funding that they need to provide the service with the expectation that they meet their contract objectives, not that they think they might meet them, but that they will meet them and that we will have

direct access to those beds. so yeah, hsa is embarking on something we haven't done before, but you know, like the gentleman behind me said, this is really different and for and i think our system citywide needs to adapt. i think it needs to adapt quicker than it has. i think you're seeing on the law enforcement side that we've adapted very quickly and we're having some really positive outcomes and getting some dealers off the street. it's just a start. it it's incumbent upon us to adapt our service delivery system and i think hsa needs to be a part of it. thank you, director. you're welcome. i don't see any other questions from colleagues. so madam chair, i think this would be a moment to go to public comment. thank you. supervisor mandelman mr. clerk, can we please open this up for public comment? let's begin public comment. if you have public comment, please line up along the western side of the room. i'm pointing it out with my left hand and then come forward to the lectern when it is your opportunity to speak. if we have anyone who's ready now, please come forward and. hello

good afternoon, supervisors again, my name is tom wolf, recovery advocate, san francisco has been beset by missed opportunity after missed opportunity to address its drug and homeless crisis in the city. if you think back to 2020, with the pandemic, we did shelter in place hotels where we placed 1200 people off the street into low barrier hotels. we had an opportunity at that time to meet them at the door with treatment, with buprenorphine, with methadone. instead, we met them at the door with alcohol, tobacco and marijuana, and subsequently 5 to 10% of everyone placed in shelter in place. hotels died of a drug overdose inside those hotels, a tragic missed opportunity to bring recovery to san francisco. fast forward to the tenderloin linkage center, san francisco spent $26 million on the tenderloin linkage center. it linked 1.7% of the people to treatment, with no data on how

many of those people linked to treatment actually went into treatment. and then they said that they reversed 330 overdose deaths, but they don't tell us how many was it? actually, 330 human beings that all died once or was it 33 people that owed ten times? we still don't. we still don't know. so the point i'm getting at is that we have an opportunity here now, today, starting with this conversation, starting with this group of people right here to talk about bringing real recovery solutions to san francisco, about funding drug treatment, about changing the culture. so that we can create climates of recovery in this town. because too many people are dying on the street. i've lost 17 people that i know to drug overdose on the street, and that's unacceptable. if 17 people had died from gun violence that were friends of mine out here, or if 3000 people had died of gun violence on the street, our response would be completely different. so i implore you all to let's keep talking about this and keeping this at the forefront of our conversations in san francisco

recovery. thank you. thank you. let's get the next speaker, please. my name is yolanda katsuko and i'd like to say something. this country, the people, the especially the children, the youth, the teenage years, we have a conscience. and i think people should take that into consideration. there's a war going on in the middle east. the people have a conscience. they resort to drugs to cleanse their soul, to cleanse their mind, to cleanse their spirit. enough of that war in gaza, cease fire. that's one of the things i wanted to mention. the other thing is this health if you have a terrible health issue like i have with my arthritis, i turned to alcohol about a month ago and i've been i drink alcohol once a week. can you imagine if you're homeless and you have a health situation of course you're going to turn to drugs. they're cheap. that the thing is this. i've been here in

the civic center and i witnessed the ambassadors talking to people. i know a couple anglo-american couple that were using drugs and they told them they had to leave because drugs are against the law. what kind of ambassador are those? and those are the ones that were elected to be the card representatives and the other thing is this. this this country that drug overdoses endemic, the united states has the way it was founded and people have a conscience and they turn to drugs. and china, the only way they were able to finally get rid of the opium opium crisis is through a communist revolution because it wasn't just the drugs , it was the housing, the health care, the food, the transport station, the education and that's never going to be possible under captain ism. and so what i'd like to say is i know that fentanyl is ugly. i know they're saying it's coming from china. i've read reports and gavin newsom was there. they

talked about it. it's about time that china recognizes what it's supposed to be. a communist country and stop that exploitation at that at that fentanyl is concluded. thank you for sharing your comments. can we have the next speaker, please . good afternoon, chair and committee members. my name is eliana binder. i'm the policy manager for glide and a member of the treatment on demand coalition on glide urges full implementation of the vision of treatment on demand. san francisco can and should be a city where those seeking services for substance use or mental health treatment easily access culturally appropriate affordable care in the face of the overdose crisis and pressing mental health challenges, our city must embrace evidence based public health solutions, including well funded and staffed low barrier treatment services for all. the city should implement dfs's overdose prevention plan and wellness hubs with urgency so that the

public health led, community driven plan can be fully realized. coercive and punitive methods are not the way forward. lead with love and inclusion over a sustained period of time is essential so that people feel safe accessing services. we must proceed with a fully funded public health approach so that we can improve health outcomes, save lives and increase community safety and cohesion. thank you. thank you, eliana binder, for sharing your comments. could we have the next speaker, please? hello, supervisors. my name is sheba banda. i'm a glide policy associate and a member of the treatment on demand coalition. i'm here in full support of strengthening our city's behavioral health continuum of care by fully implementing the voter pass initiative to have treatment on demand in a year. full of nothing but harmful rhetoric towards the poor people struggling with mental health and the criminalization of people who use drugs. i want to

highlight a few positives that have been silenced over the wave of regressive policy proposals under the umbrella of public safety. one. the creation of overdose prevention plans, specifically focusing on the black community, which is experiencing overdose deaths at a rate five times more than any other racial demographic. my community is dying, and we need culturally responsive care that is not siloed in the criminal justice system. number two, the expanded weekday and weekend hours of the behavioral health access center and pharmacy. so folks who are in crisis have a place to go and can access their medication. in number three, the at home and meet people where they are distribution of buprenorphine. and number four, the opening of the 70 bed treatments for veterans on treasure island, a population we know that is often left behind, despite all they've done for this community and this city. number five, the supportive housing pilot for brave buttons, because we know that peer support goes a long way in building trust, which is a key factor for people who use drugs.

we understand that has limited capacities to handle the overall demand, and we advocate for the expansion of existing funds to cbos in an effort to get us all closer to the collective goal of achieving behavioral health infrastructure. that's san franciscans deserve. now, it's not surprising to me to see the lack of community representative who's in this room compared to the overwhelming presence of the criminal justice system, especially when we discuss a community issue, i urge you all to prioritize the needs of my community, me, and start funding community based programs that lead to healthier outcomes. thank you for sharing your comments. can we have the next speaker, please? good afternoon, supervisors. i prepared something but then i got triggered, so i'm just going to i'm just going to speak from my heart. one one thing i want to say is my name is lydia bransten. i'm the executive director of the gubbio project. that we i agree wholeheartedly

that abstinence based treatment is a good thing. i believe wholeheartedly that medicated assisted treatment is a good thing. i believe wholeheartedly that harm reduction and outreach services are a good thing. it is disappointing for me that we always find ourselves kind of in this battle for ground as if there is a pie that we need to split up instead of working together for, because where for the abstinence programs have said that they're not going to work with the people who are not interested in treatment. there are those of us who are who may get to the abstinence programs. do not forget that the work that we do on the ground every day is part of a foundation mission for reminding a person that they are a person who is cared about and loved. i have a person in my program who has been coming to our program for two years, has never spoken a word. the other day he asked me for a bubble

ball. now people may say, hey, why are you giving that man a bubble? we ended up having a convo nation. this is the first conversation this person has had in two years. he opened up a door. these harm reduction supplies are not just a tool to stop people from from spreading disease and. but they are a tool to connect people who otherwise guys do not come to services. please don't forget about the people on the ground. when you ask what is it that stops people from doing this work? it's the constant. not only are we underpaid, we're constant under like being just told that what we're doing is killing people, that supervised consumption sites are a mortuary. outrageous. thank you, lydia branston, for sharing your comments. could we have the next speaker, please. good afternoon, supervisor myers. i'm laura thomas with the san francisco aids foundation. and first of

all, i want to say a large and ongoing thanks to supervisor mandelman for continuing to raise this issue, for continuing to focus on it. i appreciate your concern. renewed focus on this for sure. i also want to say, hey, i really appreciate the department and public health under dr. keenan's leadership and the way in which their report has also, i think, really stepped up year after year and provides more and more of the data that we need to push this city to do better on all of these. as i continue to maintain that we still need better measures of what the need and what the demand is on this. and so i'm gratified to hear df say that they want to continue to work on really getting better population based measures for the need. the san francisco aids foundation is a licensed

substance use disorder treatment provider. we've provided treatment for many years with a focus on gay, bi and trans men who use meth. we also manage the syringe access collaborative for the department of public health, and we distribute naloxone by the thousands of doses, tens of thousands of doses in san francisco. and we're really proud of all of our staff and people who use drugs who reverse those overdoses. we recently had one of our stonewall graduates parties, which is honestly one of the best events that we have at the san francisco aids foundation. but in particular, i want to lift up these issues around pay parity, because one of the things that has been happening is that as df dx tries to fill their positions, they pull from those of us in the nonprofit world who are paying less and can't offer pensions. and so what becomes solving df's problem then becomes ours. so

thank you. thank you, laura thomas, for sharing your comments with the committee. can we have the next speaker please? hello, my name is philip lassiter, formerly of the san francisco aids foundation. now in transition. my decision to come here was last minute. otherwise i probably would have dressed differently. but the realm of public comment, policy, advocacy and activism is new to me, and i'm still learning. a couple of my mentors recently told me that it doesn't always have to be a fight or that it can be a productive exchange of information in hopes that we will hear one another. the information i bring is from the perspective of harm reduction and recovery, which in itself is harm reduction. it is from lived experiences which resemble that of the communities we are serving. it includes homelessness, survival, sex, work, criminality, mental illness, physical and psychological trauma, isolation, hiv, hepatitis c, ptsd, and several very near death experiences. i have been in

recovery for 21 years and have maintained total abstinence for the past ten years. after 26 years of drug use, i'm concerned about any movement toward a punitive approach to addictions, treatment and sustained recovery . we it took not a village but an army of resources. individuals programs and services spread over an ocean of time for me to reach a place of sanity and stability. many indispensable organizations blessed my journey, and though i was arrested four times, jails were not among them. i i'm not saying i shouldn't have been arrested for criminal acts. i'm saying that punitive measures had no impact on my desire to make existential shifts to my design for living where substance use was concerned and if anything, forced abstinence only made me more resistant to the idea of treatment. fortunately for me, my drug of choice meth was not one that i could overdose on easily after periods of forced abstinence because of a lower tolerance. that is not true for people who use substances with a higher risk of accidental overdose. for them, forced abstinence can be deadly and that's i guess i'm

running out of time. but what i will say is that also my experience as a white person with law enforcement differs greatly from the experiences i've heard from my friends who are people of color. thank you, philip lassiter, for sharing your comments with the committee. could we have the next speaker, please? hello i'm jackson west. i just want to say a couple of small points. treatment on demand probably should start not just on the street, but in jails as well. the amount of resources for treatment are limited. at best. they're. and ultimately right. my other point is treatment should include medical treatment and mental health care treatment. it's my belief that dual diagnosis should be the start, not necessarily the should be the assumption and not the exception. and ultimately,

from zero tolerance to the pay issue to the workplace retention issue, to me, they all sound like housing issues. i know that there is permanent affordable housing set aside for teachers within the city budget. i don't know if there are for health care workers or clinicians. also so the city funding for education should probably address this, but ultimately i believe that housing on demand would address a lot of the issues that treatment on demand is, is has as its goal. thank you. thank you, jackson west for sharing your comments. can we have the next speaker, please? hi, i'm bravery scott. the mobile ization chair for hiv network. i'm a case manager working with homeless veterans and i've struggled in the past with finding adequate bed space

for my clients who have drug issues to get treatment and recovery. i wanted to say that healing and recovery is not linear. someone can hit rock bottom after they've gone through the legal proceedings because as you know, after they went through the legal proceedings and got arrested, they lost their job and now they're homeless. and now that makes them use drugs even more and exacerbates the problem. healing and recovery in that desire to get clean and sober can happen at 2:00 on a saturday afternoon after having an intervention with family members . it doesn't specifically happen during working hours, and there needs to be more staff trained staff who can adequately help the means of people who are using drugs just because something is dangerous doesn't mean that someone won't do it. and we need to adequately plan and help those who are going to

use. um, and thank you so much. i really appreciate being here today. thank you. grace scott, for sharing your comments. let's have the next speaker, please. hi, my name is david counts. i'm am in district two. i live in district two at eddie and van ness. i consider the tenderloin my hood, basically, because my doctor's there and i buy groceries there. i walk through there every day. i also, as a private citizen, citizen, hand out harm reduction supplies to encampments. and anybody that i find along eddie street, for example, who happens to be using and i can identify that they something that they might use or need also in that i supply my distribute wound supplies. nobody talks about this when they talk about harm reduction. that's one of the big things that harm reductionists do is we

hand out wound supplies and you know, to help with abscesses, help with cuts. when i was handing out some harm reduction supplies, somebody had just gotten bit by a dog. i happen to have a kit ready to help that person clean that person up. so we have a misunderstanding. i think overall of what harm reduction is. i have a nephew. i got involved in harm reduction when a good friend of mine son died of an od, accidental od. and then my good friend who had been sober for quite some time, took a hit of crack out of despair because of the loss of his son, who he got sober for. fortunately, somebody there had narcan with them and he revived, whereas with his son, unfortunately, nobody had narcan . it was accidental. it was completely out of nowhere that this happened. and so that's how

i got involved in harm reduction. and along with my own recovery program, i recover program. so. i would say that i just want to say to you is that that harm reduction is more. okay, sorry, i'm just going to quit right there. thank you, david towns, for sharing your comments. can we have the next speaker, please? hi, my name is marsha hoffman. i'm a member of positive directions equals change. i just want to like give like a positive like note on. they've really helped me save my life. i was homeless. i was incarcerated. and, um, you know, i suffered with drug addiction. i really, um, only like aspects of harm reduction. i really, like, believe in abstinence based programs. i feel like there's homeless outreach that can provide just like, the same similar, like food, um, bandages , like, help with that. but i

don't believe in handing out needles. i don't believe in handing out pipes or anything like that. i feel like it further enables people into their addiction. for me, i was a needle user and like i did not appreciate when people did have needles. i really don't. so i just wanted to say that, you know, positive directions, equal chains has really helped me a lot in my recovery. it has helped change my life completely . i've been through their stabilization center. billie holliday. i've gone through some of their programs, one of their programs, her house that helped me learn how to live a lot better and get more stable in like finding a job. and now i'm in a transitional housing program and it's helped me a lot . i'm actually stably working a job now and consistently paying like room and board fees and stuff and looking forward to more housing. but thank you so much. i really appreciate your time. thank you so much for

sharing your comments with the committee. can we have the next speaker, please? my name is keesling knutson. i'm with positive direction that i stay at the center. if you told me in my recovery journey that i would be at a supervisor meeting for 4.5 hours, i'd say you're crazy, but i'm here. but what i heard today was like a little story stone soup. you know, a soldier came into a village. he was hungry. he asked the villagers. they had some food. they told him no. he said, i'm going to make stone soup. so he started boiling some water. he threw some stones in it. anybody got any salt? oh one of the villagers put some salt. anybody got a cabbage? somebody threw a cabbage. so on carrots, potatoes, etcetera. and that's what i'm hearing here today. but the thing is, is that the soldier who came in there hungry with no food, all he had was

some stones and threw them in that hot water. but he fed everybody. he was the cook. i didn't heard the district attorney's office, the public defender's office. i didn't heard a department of public health health. right 360 positive direction every body it just seems as though we just need one cook to put all the ingredients together and feed everybody. thank you. kiesling for sharing your comments with the committee. could we have the next speaker, please? good afternoon. my name is leontyne collins. i'm a part of positive direction to. they have stabilized me from alcohol. i'm also worked for cold tenderloin. i'm the community community engagement special specialist, and i thought we was talking about treatment on demand. so right now we do. at cold

tenderloin, we have a night navigation. and so when we run into people, we have nowhere to take them at. we have nowhere to when a person is ready to go to recovery, we have nowhere to take them. so just like y'all did with the lincoln center as an emergency, let's do our emergency drop off center for people can be able to when they're ready, they can stay there. go back into your archives and look at odds and non odds and was a place where everybody knew where it was at once they got there on the map, you go there and you at 3:00 in the morning, you walking around, you can go knock at the door. they open the door like the 20th thing. what you want, you go in, they have you for real. they have people that you sleep on the mat. and then around 9 or 10:00 in the morning, they'll wake you up and ask, what do you plan on doing today? so the ones that wasn't ready for recovery, they would walk out the door. the other ones they would make room for them to go upstairs and wait until a program came available. since there's no beds

around. right. you're saying there's no beds around and then the beds that i was hearing, they're talking about giving it's way more people out there than that. i don't know where they're getting their numbers at . you need to go through some of these alleyways and different places. but i really think we need to do an emergency since winter is coming. we need to do an emergency demand treatment center right now. thank you. leontyne collins, for sharing your comments. let's have the next speaker, please. hi i'm leah paradiso. i am the harm reduction coordinator at taman bhutan navigation center. i am a recovering alcoholic and addict. i am a mother of two young children here in the city that have never seen me use and a lot of that is because of medical assisted treatment. one of the doctors here today was is amazing. it's also because that doctor let me do harm reduction for years, for years, because as you said, it's hard to stop

doing drugs and alcohol. it's not that people don't want to. they are not. i have so much to say because i met a navigation center right now where we're struggling to get people that want recovery, recovery. i mean, i could tell you time and time again how difficult it is. i've worked there for two years. the case managers who are very well versed struggle and the window of willingness is so small. right. it's so small and it is ridiculous. but at the same time, i'm hearing that you know, harm reduction is evidence based. it's evidence based. and i'm hearing this person that was up here before saying that they want to take people's money away because it's illegal to take their money away and test them. but we will go around some loopholes and take that money away that is keeping them alive, making them eat this is a compassionate city. maybe not having them out on the street because they can't stop using

drugs and alcohol. i just i'm proud of this city. i love this city. this is a compassionate city. let's not go backwards. let's go forwards. thanks thank you. leah perez, for your comments. can we have the next speaker, please? hi. thank you. board of supervisors. my name is donna hilliard. i am the executive director of code tenderloin. i just want to thank you all for your time today. we heard a lot of really good, amazing things. and i wanted to touch upon a couple of things. i heard that there is a need for workforce as code. tenderloin is a workforce development nonprofit. we have been training people to get into jobs for seven years. two years ago, i presented to the city a program that was training community health workers, people to get into public health. i was not able to get that funding from the city. i then went and rallied the money from tech companies. yes the tech companies fund this program that code tenderloin runs and is very successful getting people to run and work in these different drug

treatment programs in i mean, we are everywhere. we are in soma rise. we are are running some of the navigation centers, you name it. these are folks with lived experience who we are teaching to take that lived experience and turn that into a career and make the best of that and climb the ladder. and so we do now even have people who work in dpi. we have folks on the best team. i mean, it's amazing to see the ladder how people come into one position and climb up. there is a solution to this and we have a fix, we have a graduation that's on november 17th. i would welcome you all to come and see the graduates who are coming out of this. some of these are people who are graduating from long term drug treatment programs that are now starting their careers. we know that there's not enough peer to peer support out there, and we must do more to have that happen. we do have a nights and weekends team. we knew there was a need to be out there 24 hours a day to support the folks that are out there using drugs and we're having those conversations

with them. we're not just giving out harm reduction supplies, but we are talking about recovery. we are talking about suboxone. we are talking about all those things. and we are getting 8 to 9 people into some type of service every night with a four man team. so let's do more together. thank you. thank you. donna hilliard, for sharing your comments. can we have the next speaker, please? hi, good afternoon. jennifer friedenbach, coalition on homelessness. thank you so much for holding this hearing. i know it's been a long one. i just wanted to note, um, there is a lot of things in our system that are not working. and i know i heard you heard a lot of those today. i just want to kind of zero in on a few things as one of the things is the connection trauma has to recovery. and if you have severe trauma, whether it's diagnosed as ptsd or not, and you have a lot of money, there's a lot of really great therapies that you can get in order to address that

trauma. you can also get them at the va. if you're a veteran and i know a lot of folks who have really successful fully addressed their substance use issues through that process. and that's a big piece that's missing. i think another big piece that's missing is having really specific recovery programs that are serving particular communities. we have a massive shortage of, for example, if you're spanish speaking or mayan speaking or mandarin speaking, we really don't have a system set up for you that that not only speaks your language, but is also culturally appropriate. um, and that goes the same for services in black communities. indigenous communities. and having those really supporting those communities. samoan community, each have their own very unique set of issues that are connected to, you know, to their own people. that's a lot more successful if it's done in that way. i think we blew it. on the opioid settlement funds. i think that could have been an

opportunity to do a lot more. i also want to talk about the medical treatment that we have a we have medically assisted treatment that works that is so overregulated and so complicated. it's almost impossible for people who have addiction disorders to be able to navigate. thank you. thank you for sharing your comments. jennifer friedenbach, can we have the next speaker, please? my name is gary mccoy and i was this close to identifying myself as if i were in a much different meeting. so always a concern of mine. i am vice president of policy and public affairs with healthright 360 during the j 24 hours a day, seven days a week. i'm a person with lived experience. i am in recovery and i work a fairly solid program of that. i. i agree with a lot that was said today. i think there was a lot of common ground. i think too often things are way

too politicized, especially a crisis of this magnitude and importance that's been going on for far too long. i do implore everybody to continue working together for it. we should be working to build a full continuum of care regardless of where folks may be at that point in time in their life. and i and i do think that we should be asking our providers how we can help while asking the people we serve, what we can do to best make their lives a success. so thank you. thank you, gary mccoy, for sharing your comments . next speaker, please. and if we have anyone else who's ready to give public comment, if you could line up along that wall there, we'll get through each of you. hi, supervisors. my name is andy stone and i'm with the san francisco aids foundation. and i help coordinate the hiv advocacy network, which is roughly about 800 folks in the city who are hiv and lgbtq activists fighting to end the hiv aids epidemic and to improve the lives of communities most impacted by hiv

. and as we know, substance use is a huge issue not only for hiv communities, but also for lgbtq folks. i think it's absolutely critical that we not waste time pursuing initiatives that are actively harmful in the midst of an unprecedented overdose crisis that is killing hundreds of people and that we not pursue things like criminalization that only serve to disrupt the ways in which people are trying to live day in and day out without addressing some of the core needs that they're facing around housing, around food, around and low barrier access to treatment so that folks can actually get into aa and that can build relationships that allow folks to progress in their journey around recovery if that is the path that they wish to pursue, we need to continue to support evidence based treatments that are harm reduction based, and we

need to support the dignity of people who use drugs. we need to stop stigmatizing people, stigmatizing people, criminalizing people, pushing people underground. and these don't open spaces for people to be able to access the critical services that they need. it doesn't allow them space to be able to talk to their loved ones , to be able to get the social support that's so critical to recovery. so i urge you also, as the city is thinking about what our policies and solutions to this, that you really look at what the treatment and service providers and addiction and disease specialists and more importantly, people who use drugs and people in recovery are saying and that's that folks need a system that actually works. thank you. thank you, andy stone, for sharing your comments. do we have anyone else who has public comment on this agenda? item number three, madam chair. thank you, mr. clark. public comment is now closed. supervisor dorsey thank you, chair stefani. i want to express

my gratitude to everyone i know many of the folks from departments and advocacy organizations have left, but for if they didn't hear it, i, i appreciate that the work that went into all of the presentations, i appreciate everybody who stayed for the for the duration of this to make public comment. but i want to especially thank my colleague and my friend rafael mandelman, who i know has been leading on this for a long time. and i will say that even as someone who, you know, long before i imagined i would ever be a raphael's colleague, he was a friend of mine, i turned to in moments of difficulty and was helpful to me on a personal level. and that means the world to me. i want to thank catherine stefani as well for her leadership. and joel, i don't want to leave you out, but i think this catherine and raphael have been doing this work before we got here. and i just want i want to acknowledge that. and lift it up and honor

it. i have been out and open about my own journey in recovery and the fact that it was the combination of the crisis that we're facing in my own journey in recovery from addiction that moved me to ask for a job i never thought i would want, let alone have. so this is personal to me and i guess have lived experience. but i also know that my addiction qualifies me to judge my addiction. and if i'm being honest about that, i don't have a great record of judging that sometimes. but lived experience is something that it doesn't provide insights any better than anybody else's, but it makes my heart want to do everything i can in this. and i know that there's a lot of heart here today that even when we disagree, i really appreciate something that my friend gary mccoy mentioned about the importance of working together. i think you know that i support

the harm reduction, and i think as much of a advocate for abstinence based recovery as i am going to be, as i have said and will say again, harm reduction is about saving lives, making sure that people are alive for the promise of abstinence based recovery and a life without free of drugs or alcohol or for that matter, non substance related addictive disorders. so the things that we can do to help people there was one slide that i just wanted to that resonates with me because it's a perspective i didn't have before i got here, and that was when destiny was making a presentation about what it is, what it means. these open air drug scenes mean to the community, and i think i have grown to see that we have. i have neighbors who are as close to pitchforks and torches as i have ever seen in 30 plus years in san francisco. and all of it is about drug scenes. and while

i appreciate that, when people talk about the terms like criminalization of drug use, we exist in a democracy of people who are have legitimate questions about why we who are pointing out to us that it is actually a crime and have legitimate concern about whether government even cares when they see a kind of lawlessness going on in their neighborhoods, that is robbing them of the safe enjoyment of their neighborhood. and then it's i think, even more galling when the city is doing a very good job of making sure that their cars are ticketed. and there are things that we're doing that's losing people. so one thing about working together , i hope that the advocacy community and policy makers and all of us can work more closely and influentially with the community to win their hearts and minds for what we're all trying to accomplish. the original and i'm just looking at it now, the original harm reduction policy in the city and county of san francisco was adopted in september of 2000.

and in right in the opening, it said, you know, this is about reducing harms to individuals to individuals, family and to the broader community. so i do want to make sure that when we're having a harm reduction conversation, we're also taking seriously what we have to do to address the community's sense of harms. because if i think if we can do that, we can probably turn the temperature down on this and i'll make progress together. so my gratitude to everybody, i have learned a lot and i just appreciate everybody's time. thanks. thank you. supervisor mandelman uh, thank you, chair stephanie and colleagues for sticking with a five hour hearing or 4.5 hour hearing. i do think the topic deserves it. i think this is if not the most pressing issue facing san francisco, among the most pressing issues facing san francisco. i do want to thank zahra hajji and my office for the work that she did and coordinating all the folks who

presented. i want to thank the presenters. i want to thank everyone who showed up to talk in public comment and, you know, in a city of where we where we manage to argue about lots of things and i think we certainly can find some space to argue about things in the substance use conversation. and we will argue about those things and there's little whiffs. i don't think the board is. is as i said, i don't think anyone on the board of supervisors believes that medication assisted treatment is a bad thing. i think we all think medication assisted treatment is a win. and i also think that there is broad agreement that that we want to be a city that makes recovery, that makes recovery easy, that makes it never will be, but that it's not

being made harder by things that the city is doing or a lack of funding or creating programs that to the extent we can, we should be making it easy for people to access buprenorphine to get into a residential program, um, to step down from a residential program to an appropriate step down facility to do all the things that are going to lead people to live longer, be more productive, have happier lives, and i think the value, the reason i keep insisting that we do these hearings each year is i do think that that original framework of setting that goal of treatment on demand and then forcing everybody to look at where we're falling short and then trying to make city departments grapple with how to close that gap is a valuable exercise. and we've gotten better reports and it

sounds potentially from some of what we've heard today, that maybe there are some areas where the gaps maybe have gotten narrowed a little bit and that seems positive. and it also seems like there is a ton of work to do. there's another one of these reports coming in february. we can talk about it in 2024. and i do want to thank the department of public health and thank director collins for taking this seriously. i think she does take this seriously. i think they are trying to address this problem. and i also think that we are still far, far further than we ought to be from actually understanding what the gaps are and how to close them. so with gratitude, but also with urgency, you know, let's look at let's get ready for the next treatment on demand report in 2024. and i would ask that a member of the committee make a motion to have this hearing heard and filed. thank you. supervisor mandelman. and thank you again for your partnership

on this very important issue. i think it's an epidemic that needs a response much greater than we are using in the city and county of san francisco right now. and you know, one of the public commenters said something about how she felt triggered. and i completely understand that when discussing all of these issues. i think none of us know what what the experience of us might be in this regard in terms of what family issues we've gone through , what type of generational trauma we all sit with when it comes to substance abuse and, you know, a lot of people are out and open in recovery and a lot of people are in recovery and believe that it's important to be anonymous, that the level of press, radio and film, which is part of a tradition and the aa program, so nobody knows what people are actually really going through and what brings them to

this issue. i have shared openly about some of the things in my family, certainly not of shared everything publicly about everything that i know about this topic, but i do want to say to one of the last public commenters said something that i thought was important about listening to people in recovery and listening to people with lived experience. and that was one of the first things i tried to do when i got here was to listen to people who felt that they weren't being heard, and that was the recovery summit working group. and where they felt that they weren't being heard is where i think a lot of the tension continues to come from is that people that do engage in what they call abstinence based treatment, which is usually treatment based on a 12 step program. a lot of people have said in the past that that is not evidence based and a lot of people who are living those principal goals and are living a life free of drugs and alcohol on those principles

do not like being told that what they are doing is not evidence based. and i think that has caused a lot of tension. i absolutely believe in harm reduction. i absolutely believe in medically assisted treatment. i absolutely, absolutely believe and i've said time and time again that we should offer everything we can to deal with this crisis, that we should offer every possible treatment program or treatment there is to deal with the disease of addiction. every individual suffering from the disease of addiction deserves it, just like every person suffering from aids deserves our interventions. just like everybody. everybody who was suffering from covid deserved everything we could possibly do around that. and i just keep think we're i think we're missing the mark in san francisco. i still don't feel like i know. and all of you that have spoken, all of you that are in this world and doing your best are doing your best. i know

how frustrating it is. i know how frustrating it is to watch someone continue to use over and over again when you know that they might die. i know what that feels like to my core, and i know you all know it too. and i think all of us are coming from the spot where we want to intervene in a way that helps those people get the help they need and wants to turn things around for the next generation. and when interventions are made where someone can stop drinking or stop using drugs that may help them get their daughter back out of foster care or whatever it is, that's a story i heard yesterday. i hear incredible stories all the time. i see incredible stories in my own family with just my brother and my sister and i don't think we're getting at it yet in san francisco. i don't think we're treating it as the crisis that it is. and i look at some of the you know, when we do our contracting and some of the things that came out today, it sounds, you know, and all the programs and the audit they're doing on all the different things we're trying to do, it's

a little bit of like throwing spaghetti at the wall and see what sticks approach. and i think those suffering from the disease of addiction can deserve a little bit more coordination. and they deserve all of us to put down our swords and our judgments, our implicit bias, our explicit bias around this subject act and really get at the heart of what's going to make a difference and what's going to save lives and i don't think we're there yet. i think we're getting there. and i think i know that supervisor mandelman and i will keep doing this until we feel like we've made some progress. but but i just want to say i care deeply about those suffering from the disease of addiction. it is so hard to watch in this city, people laying on the sidewalk in front of city hall, people in the tenderloin, people in my district. it is so hard to see the lack of humanity around that , that people could just so easily walk by. i hate it. and i

really want to find solutions to it. and that's why i'm so tough on people that are in this space. that's why i'm so tough on making sure that when your contracting with a city and you're saying you're going to do something that we can expect you to do it and i'm not going to let up on that. i really want to make sure that we are doing everything we can to get at this. and again, i do not think that we are doing enough. i think there needs to be an emergency center set up for this disease. i think we need to approach it like we did covid. and i just think that there's so much more we can do and i and i say that, but i also want to express gratitude for all the work that is done, because i know people are trying and i just think we all need to continue to try better together. and then i will make a motion to continue this to the call of the chair. never mind. i make a motion to file the hearing on the motion offered by chair stephanie that this be heard and

filed. vice chair engardio engardio i member dorsey dorsey i chair stephanie i stephanie i madam chair, there was no opposition. thank you, mr. clerk . do we have any other items before us today? there is no further business. thank you. this meeting is adjourned. now,

i'm saying that these are the kinds of things when we begin to screen vendors in the future will help us make decisions about appropriateness of care, the miss steps and the correct steps that are a cost to everybody, not only the members but the employer groups, etc. >> >> i know in our neighborhood, we have 2-3 urgent care. >> i can't hear you. >> we have urgent cares in our neighborhoods for sure. that's where i usual go before i go to the e. r. . some people just go to the e. r. ? >> yes. >> that's urgent care.

they will refer you to e. r. if urgent care can't do it. i know that. >> anyway. >> is there any effort to encourage more urgent care centers in various neighborhoods? because what i find is most people don't have a sense of the difference between urgent care and emergent care because of the panic of whatever is going on. they are seeking, immediately if there is nothing you can make an appointment for, they think of emergency. but urgent care is equally as competent and much less expensive, but i don't know if medical groups are considering having more urgent care options or what's out there in that way

if medical groups are organized sufficiently to do that because it's not inexpensive to set up that option. somebody has to have that office and the staff and ability to do that. so is there any trends that you noticed or not? >> i said in the director's report today that we are going to map out the urgent care centers and look at the capacity issues that may or may not exit. we all have personal experiences but we don't have data. we are going to put that together for a future meeting. >> okay, we are going to be doing that. thank you. >> so i have a question and i'm not sure i know how to articulate. the thoughts are swimming in my head, but it seems when you reminded us to our past and recent effort to introduce the plan design changes, they weren't necessarily to change behavior. we were seeking some of the

relief for the premiums for that year. how would you encourage the board to think of plan design? is it to encourage different behavior or what? >> from my perspective, it's a couple different elements when you look at considering plan design changes. we definitely talked about the cost saving element, but i do think and what we've worked with other employers on through plan design changes is evaluating what are the downstream shifts that we are seeing towards for instance emergency room care that maybe is not emergent in total with how a health plan

will categorize those type of visits. are we seeing more of those non-emergent visits shift to primary care urgent environments with inpatient hospitalization would an increase in copayment do more to encourage more surgeries that are being performed in patients that could be performed in an outpatient setting. are we seeing shifts in those services. i think there is a recollection that clearly care in these settings, there is definitely care that is appropriate for those settings, but through plan design shifts, trying to help members assess, could there be an alternative care setting that delivers a similar or better

clinical outcome that the financial differential and a plan design copayment could go into the factoring of a member working with his or her physician to decide where is the best form of care that could deliver a quality end cost optimal outcome. >> i feel like what you described requires lots of lead up conversation behind the introduction of a particular plan design change because i think what has happened in my memory of these past two events is that the conversation immediately shifted is who is going to bear the burden of the additional cost and that was the driving force of some of our decisions. i'm not suggesting that is not important but want to consider all the elements.

>> i think you characterized the most two recommendations well. they are designed in somewhat response to the level of renewal that we are getting in this case from the kaiser organization because both of those recommendations were for the kaiser active and early retirement plan. >> if i can just point out, even with the data for the effective co-pays. it was 2014, i think. i'm hoping it will be a lot more recent data. in fact, the information that you quoted from that study showed exactly what the board was concerned about. the higher co-pays had the biggest effect with people with chronic disease and that is what actually led our decision to reject the staff recommendation which is we were concerned about our members that were the most

ill who would bear the brunt and that ran corporation data from 2014 if i'm not mixing apples and oranges from my memory, but these are the things and they are very complicated and limited by the timing of the data gathering and much of it has changed. what got my attention was that in office charges for lab and radiology, may be cheaper but they are not clear license for quality. they don't go through, yeah, you may be getting a cheaper analysis, but where is the quality and who is measuring the quality in an outpatient office for your analysis and same thing with x-ray. cheap may not be quality and how

do we document the quality that is being delivered independent of the cost necessarily? >> yeah, i think working with our partners, kaiser and blue shield to understand that. i think to your first point is part of why we wanted to show the data for the average cost given by the numbers and on slide 16, the fact that the highest increases in cost over the last three years are also affiliated with those services where the member is paying less than one percent or in the case of the drugs 2% of the total cost and as small as those percentages are, they continue to reduce as the overall cost increases take hold. essentially it's the plan that's bearing those increases that we

illustrated on page 16. any other questions for mike or anne? thank you very much. we'll take public comment. >> public comment is now open. instruction are on the screen for those watching on sf govtv and webex. for those present, please stand up near the podium. and for those on the line, please indicate by pressing no. 3 to comment. >> no one has approached the podium. we'll move to our remote public comment. our moderator will notify us of any public commenters in the queue. >> there is one caller on the

phone line, no caller has entered the queue at this time. >> thank you very much. public comment is now closed. >> thank you, please call the next agenda item. >> public comment: 12.board education: determining city contributions for sfhss retiree medical plans: (discussion) presented by mike clarke, lead actuary, aon >> mike clarke, aon. there was a request at the last meeting to talk through the determination process for city contributions for the sf hhs retiree medical plans. in august, i did present on healthcare transition from active employment to early retiree status. the document here and the discussion today will summarize the approach to determining those city contributions for the retiree health plans.

where we focus more on the early retirees in august and including city charter language today. the city does cover some or all of the cost of retiree health coverage on the formula on the charter and that depends on the plan and coverage. to contrast with the determination of retiree healthcare, city contributions being done through the charter for the active employees with the memorandum of understanding and you will see the charter to this language and it's on the bottom of page two. from a total rate perspective, one question that often arises is how are the total rates determined and specifically why are early retiree rates higher

than active employee rates from the same plan? why are they higher than advantage medicare plans and why are they higher than active employees. the methodology looks at the plan per claims and per member for retirees and employees. healthcare increases with age and this is the most significant factor that contributes to this. there is also a government accounting standard that was first announced in 2004, and became effective a couple years later where cost rates are essentially determined separately for active employees and early retirees for accounting reasons. there used to be a pay as you go or cash base accounting for these plans for a cost other

than benefit pensions in other words retiree medical and those that are on an -- accrual basis. when you are a medicare individual, the government does fund the majority of those costs. those payments are determined through the centers for medicare and medicaid what we call cms. there was a nice illustration back in june that showed how that played into what mapd renewal was and i encouraged page 8 of that material for that information. for early retirees on page 4, you can see a couple of visual

examples through these bar charts of the three elements of the city contribution formula. you start with the ten county amount, then you build upon that what is called the actual difference which is the difference between the early retiree only total cost rate and the active employee only total cost rate. then there is also a prope contribution and that provides incremental funding for the retiree only but also the retiree independent. you will see the prop e amount is higher than retiree plus one and versus the only tier in those examples and for the kaiser plus.

those dollars paid by employers goes to retiree coverage. that prop e portion does provide prop e coverage. for the first dependent is the lower dollar amount and there is no city contribution from charter language for the second for the dependents in retiree coverage and there is why it must pay more to cover those dependents. the charter defined elements you will see here on page 5. the section references are here, and where they translate to in the labeling of the rate cards. footnote no. 1, in that case with the city contribution exceeds the cost rate of the plan which is why the county

amount and the medicare advantage plans equal the retiree only tier rates for the medicare advantage plans. the prop e language, specific for dependents, you can see here in section 8, which is why the prop e provides funding for the first dependent of the retiree. for medicare retirees, it works the same from a formula standpoint. the application may seem a little different, but it's again because the total rate for the plan is less than ten county amount. that's why ultimately you see 0's for the retire early plans and there is no difference because that ten county amount is funding the retiree and the

prop e portion is providing 50 percent of the first dependent's total cost rate. you can see here how that plays out for the two medicare advantage plans and in particular on the left side for the united healthcare ppo plan, we show the various combinations of retiree for two or more including those for split medicare families. so the early retiree is paying higher contributions for dependent coverage than active employees. that is a real difference that covers the difference in cost and the tiers, but the city contribution versus the city formula for retirees. the chart here looks at someone who is an active employee, mou, the city is paying 93% for self

only, 93% for self plus one, 83% for self plus two or more in most plans except that highest cost plan which is the ppo. and how that translates into early retiree for the self only, the actual difference bridges that entire rate difference for the self plus one, the city is paying 50% of an incremental cost for the first dependent and no incremental city contribution for the second and additional dependents. then also noted here at the bottom of page seven there is an important appendix page that i won't read, those hired after january 2009, that is for those

individuals after those hiring dates. that table is in the appendix. so overall, when we look at the distribution of retirees across the three tiers, about 9% of early retiree and medicare retirees cover one or more dependent. you will see that there is 802 new retirements in 2023 and the vast majority are individuals that are not medicare, 80% will become medicare and 58% within five years, but three out of four are retiring before

becoming medicare eligible and over half will be medicare eligible within 5 years. and looking as police employees and fire and all through august of this year were not yet medicare eligible, recognizing 18% will be within five years and there are 14 members who waived coverage. there are a total of 1237 medical retirees who are sworn fire and police officers and will be 40% within five years. in closing, our team will continue to calculate city contribution amount for health plans based on the city language and there are important appendix

pages for your reference. first some rate examples and you can see the application for the city charter elements for the early retiree plan and specific language for each of the three elements that determine those city contributions for retirees and contributions for those retired after january. >> can you show what people will be paying in 2024. >> commissioner, breslin, you requested to see the rates for the current 2024 year plan? yes. i think we can pull that up. i believe that is on slide 7 or

8. >> you might need to hold the microphone. >> i want people to really pay attention to this because especially the actives who may be retiring early to see what they are going to actually be paying here. blue shield will be $1575 per month for two. that means anybody over 65 years old that retire and there will be a number of people retiring. it's important that people from

the active union know that which is what happens when you retire. and that's good to put up there from that's my main concern that people can see this and what's happening here. kaiser, of course is cheaper, but blue shield is even more expensive than the city plan. $100 cheaper per month. >> i think this points out the importance of preretirement seminars that some of the unions hold, and what we do at health service with regard to educating members who come for that information. the seminars are vital for distributing that information

and alerting people. sadly, most of those seminars and i have attended a few and a lot of times the people who attend are already retired or they are so close to that retirement date that they don't have sufficient planning time, and it would be helpful for those employee organizations to publicize a little bit more through their members that people really need to take a look at this six months or a year before they retire, because these rates are shocking especially when it comes to dependent coverage. >> very shocking. >> if i can piggy back to those comments to add my own. thank you for the clarity that you have brought to the issue where most members from the police side, i know we have had preretirement seminars that i

and other commissioners have attended and seeing the math to what the expense is and the cost for early retirees for planning commission. given some trends that we are seeing with our workforce, it's not uncommon for some to transition out of city employment to early retirement >> it may be helpful to have some sort of educational material to socialize really what we are seeing now that is incorporated within some of these before people pull the trigger on retiring, they should know what they are getting into.

i should compliment you for the very robust and clear presentation and would like to thank my colleagues here on board. >> thank you. >> when it gets complicated to me is the 50% that was added on. i have an old charter here and it says application of section, blah, blah, blah,, city and county shall contribute 50% and the charter was clear. that 50% of the monthly contributions required, but the old charter says 50% of the retired person's remaining monthly contribution which was confusing to me. >> anyway, it's a little bit complicated. i can see where this is shocking. >> we don't hear you.

>> i can see where this will shock a lot of people where they retire. $19,000 a year is a lot for health insurance if you have two dependents. >> from my perspective, i think this is really an important discussion. i think it's important based on some of the comments we got in the last rate cycle where it's like just say no. i think it's quite clear to me from this presentation that hhs and the board operate from constraints on the charter and the mou's and they are not something that hss created or that there is leeway in our interpretation of mou's and that we have to live within the constraints of this. i will say vis a vis the conversation we had already was my last employer is the first

preretirement program for my peers five years before retirement. five years. so we can begin to think about what our options are and that would go into decisions around what those options might be, everything from leaving the state to retiring at that moment, whatever. but five years is not an unreasonable window for people to start thinking about this, no two days or two months or even two years before. >> any other comments or questions? >> thank you for explaining the math to us. you are the only non-city person that speaks charter that i know. [ laughter ] thank you. >> you're welcome. >> if there are no more comment or questions, we'll open up for

public comment. >> public comment is now open. instructions are on the screen for those watching on sf govtv or webex. those in person will comment first, if you are calling to make comment, please indicate that you wish to comment to be placed on the queue. anyone can approach the podium now >> public speaker: fred sanchez. very complex. obviously the charter, difficult to change the charter. it's some good comments. maybe they can look to see if they can mandate some kind of 3-5 year requirement. just a

thought. if that could be somehow mandated because who is going to protect these early retirees. a lot of people end up in that category and have a 14% rate increase that is impossible and unrealistic. i think you might have mentioned how many people opt out to just not take health insurance anymore because it's too expensive. you said something like 14%? >> the number of people who waived? >> yes. >> i would be cautious about interpreting that because many people have spouses that have employment that offer insurance. we have a number of people that waive in the general membership. >> anyhow, thank you for the presentation, very complex. maybe we can work on that

suggestion. thank you. >> thank you. any other members of the audience that would like to speak? we'll move to our remote public comment. our moderator will notify us of any callers in the queue at this time >> >> we have two callers on the phone line, zero callers have entered the queue at this time. >> thank you very much. public comment is now closed. >> thank you very much. let us now move on to the next agenda item. 13.reports and updates from contracted health plan representatives: (discussion) any of our program reps can approach the podium. >> good afternoon commissioners

and directors. i want to take this opportunity to introduce to you our new vice-president of client management at united healthcare. i'm monica, united healthcare representative and here we have jeff who is new to our leadership team. he will be new to sf hhs although not new to the team. he has been with the organization over 20 years. >> thank you, good afternoon. jeff franzy, vice-president. i have been with united healthcare for the past 22 years which i have spent in client management and the public sector space. i appreciate the opportunity and looking forward to working with all of you.

>> welcome. >> thank you very much. >> anyone else? >> all right. >> cate, kaiser permanente. i wanted to say to the board that we did have a dmac find given to us a couple weeks ago and we will be working obviously started over a year ago and working to rectify that and we have made significant investments in major medical healthcare including hiring over 600 new therapist and invested in new buildings and contracting in the community. we will keep the executive director informed as we move forward and wanted to let the board know that we are

taking this very seriously moving forward. >> thank you. >> absolutely. >> all right. we will take public comment on the report. >> thank you, vice-president. >> public comment is now open. instructions are being displayed for those watching on sf govtv and webex. in person public comment is first then remote public comment. please indicate to be put on the queue, for those on webex, please raise your hand to be placed on the queue to speak. no one has approached the podium. we'll move to our remote public comment and our moderator will notify us of any public commenters on the queue. >> we have two callers on the phone line and no one has signed up to speak. >> thank you very much.

public comment is now closed. >> next agenda item. >> public comment: 14.vote on whether to hold closed session for member appeal (action): >> we have an appeal and we will vote as to whether or not to go into closed session. may i have a motion? >> so moved.. it's been properly moved and seconded. do we have public comment on this item? >> we will call public comment. and -- public comment is now open. instructions are being displayed on the screen for those watching on sf govtv and webex. in person comment will be called first and then online public comment. for those watching on webex, please raise your hand to be placed on the queue to speak.

we'll begin with in person comment. no one has approached the podium. we will now go to online public comment and callers on the queue at this time. >> we have two callers on the phone line, zero callers have entered the queue at this time. >> thank you. public comment is now closed. >> we will take a roll call vote, please. >> [roll call] >> >> all right. it's been unanimously approved that we recess into closed session. thank you, everybody. that means all parties not party to the closed session must exit and we will do all the virtual shutdowns as necessary. >> i do want to recognize that

member dorsey has arrived and will be present. >> ( closed session ) >> [captioner on standby] >>