Deduction to San Francisco filers so we think that its about 2. 1 billion for the state and local tax dedukd deduction a lot smaller, i dont know, 100 million or so in the property tax deduction. Supervisor cohen so overall theres less revenue going into the state budget and the local San Francisco budget for us to then reallocate during the budget process . I dont think that its a direct affect and if you take 2 2. 1 billion out of the local economy, you have to expect that it will affect the local business ability to invest or to expand supervisor cohen to hire. You have to expect that Discretionary Spending would decrease because the cost of necessities is going up and it would certainly affect your sales tax. The effect on the Housing Market and our transfer tax and the property tax as a result seems like it would if anything it would have to possibly drive down prices and just reflecting the fact that most buyers are going to have higher costs to finance and then pay taxes on these new purchases that one would think that it would depress slightly the home prices but not in a way that will substantially benefit. Supervisor cohen so in the news that i was reading earlier this morning, i think that there are republicans from california and other high tax state theyre putting pressure on the congressional leaders to make some considerable changes that could avert some of the most severe impacts to us being felt here in california. Can you describe maybe if you dont know it just let me know that you dont know, but what exactly is our congressional delegation doing . I know that two weeks ago in a very public way that pelosi was set to meet with the president but then the talks were derailed because of twitter. So where are we what are our lobbyists telling us in terms of in sacramento and in the capital . I am receiving updates from them as theyre sort of more able to get current information. One piece of information we got from our federal lobbyists yesterday is that theres a bipartisan bill and i dont know who the sponsors are on the spot, who would seek to maintain more of the salt deduction, maintain the property tax deduction, and pay for it with i think that it was a passthrough proceeds to kind of shift that a little bit more in favor of toward the individuals and less in favor toward the businesses. Thats one proposal from two congress people. Im not sure where that is, if its where that is in the process. Supervisor cohen okay. Supervisor fewer, did you have questions, i see your name. Supervisor fewer thanif superk you, i just have a comment and i think what we may see from this is that individuals who are trying to get into the home market, the Real Estate Market here in San Francisco, will have a harder time because its so expensive to buy a home here and when you cant deduct your taxes it doesnt give you some relief at the end of the year. Because the relating corporations are taxed at a lower level it just encourages corporations, quite frankly, to buy real estate because they can take a hit on not deducting on the property tax because theyre also leveling it with a generous tax package for the corporations. So i think that this is actually very detrimental to all of the housing that were building that is at that price range that were trying to get at with the new home buyers and this will hit them hard. And speaking of someone who just bought their first piece of property in San Francisco as were building them for them is that this group of people actually will have a harder time getting into the market considering they will not be able to get deduct these things on their taxes. And so i see the effect actually hitting the people that we actually wanted in San Francisco versus the corporations that buy up a lot of real estate here that are going to get a huge break with this tax deduction. Lets just hope that people have a moral conscience and thats farfetched, i know, and well pushback on this but i think that we are i mean, its hard to see what the changes might be because everything is in flux but just looking at this i think that it could really hit a lot of San Francisco, but what were trying to do to get people middleclass folks in sa San Francisco to invest in a small piece of real estate here, its going to be detrimental to that effort. Supervisor cohen definitely. Any other tax wisdom that you want to share with us . Not at this moment. Ill turn it over to cindy comerford from the department of Public Health with an update on affordable care. Supervisor cohen okay. Okay, good afternoon supervisors, my name is cindy comerford and i manage the policy and planning at the department of Public Health and today im going to give a very brief presentation on issues that Impact Health care reform. These are not all specifically around the a. C. A. But somehow impact our ability to provide health care in San Francisco. So im going to talk about six issues that are on the slide in front of you. Im going to give a very brief update on each one and some of the funding mechanisms, theyre very complex so im happy to answer any questions at the end. So the first item michelle already talked about at length which is tax reform and tax reform could potentially impact the Health Care Landscape very significantly. As michelle said, one of the biggest issues is the repeal of the individual mandate. This is a component of the a. C. A. That requires most individuals to have Health Insurance or face a tax penalty. This is in the senate bill. There are also a couple other items within tax reform specifically, the elimination of the medical expense deduction and the elimination of the Student Interest deduction, and also the orphan drug industry deduction is eliminated. Or capped within the senate bill. And these bills are in Conference Committee right now and were not entirely clear whether the house will adopt the senates bill. It kind of goes back and forth each day. This morning it seemed more likely that they would include the individual mandate but a couple days ago that didnt seem feasible. So its still pretty fluid on whats going to happen. The potential impact of repealing the individual mandate would mean 13 Million People would have would not have insurance. And it also impacts premiums by causing them to increase. So that 13 million translates if you do a straight statistical calculation about 35,000 residents in San Francisco. In addition, since the tax cuts are so large it could potentially trigger an acrosstheboard spending cuts and this would impact medicare. And in order for it not to have impact on medicare, there would have to be federal legislation passed that would protect these Additional Health care programs. So the next item that ill talk about is the childrens Health Insurance program and also known as chip. And chip is a federal and state partnership that is designed to provide lowincome children with Health Insurance coverage. This Program ProvidesHealth Insurance to about 1. 3 Million People in california under the age of 19. So the funding for this program expired in the end of september. And traditionally this program has enjoyed bipartisan support but, unfortunately, its kind of become a political tool. In october, the house did pass a bill that would extend this funding for another five years. It was passed primarily along party lines and mostly rejected by the democrats because of two reasons. One, it took funding from the prevention and Public Health care fund which is the only federal dedicated fund to Public Health. And it also changed the window in which people could be late on their Health Insurance premiums and so it would increase the amount of people that would get kicked off their Health Care Plan for nonpayment. And so the Senate Negotiations in the senate have stalled, right now potentially we could see a bill passed by the end of the year, although right now i think that Congress Main priority is around tax reform. So its unsure whats going to happen and the a. C. A. Has i maintenance of effort clause which requires the states to continue this program through the year 2019. So california would have to pass legislation to determine how it would move forward with funding this program in the absence of a bill being passed by the end of this year. And theres approximately 15,000 children in San Francisco that benefit from this program. So the next item is the disproportional hospital payments and its known as dish payments this makes payments to hospitals that serve large number of medicaid and underinsured individuals. So based on the assumption that with the aeca that there would be more increased coverage and less individuals uncompensated it called for a reduction in these payments. So these payments have been scheduled within d. P. H. s budget and they were to start in the year 2014 and they were delayed to 2017, but in the chip bill that we just talked about that the house passed it has a delay of another two years, but then having a really steep reduction after that. So right now we have a scheduled 11 million reduction for this fiscal year that would increase to about 39 million by the year 2024. And these payment schedules may change depending on what happened at the federal level. The next item is Community Health center funding. And Community Health centers are communitybased and patientdirected organizations that typically serve communities that have limited access to health care. So federal grants are a key component of the funding for these Health Care Centers through the Health Center trust fund which includes both discretionary and mandatory funding. So as are the chip bill, this funding the mandatory portion of this funding sunsetted in september. And the house bill did include funding for Community Health centers for another two years. So california could potentially lose over 300 million in funds if congress does not extend this funding for over 1,200 Community Health centers in california. The San FranciscoCommunity Clinic consortium which is a collective of the San FranciscoCommunity Health centers, estimates that the funding loss to San Francisco would be between 5 million to 10 million with about a Million Dollar impact to d. P. H. And the next federal item that i want to talk about is the Opioid Crisis funding. This is not directly tied to the a. C. A. But there are some potential avenues to increase funding to d. P. H. So i wanted to mention it and i know that everyone here is already aware of the Opioid Crisis. In 2016, we had more than 64,000 people nationwide die of overdoses to opioids. And drug overdoses are now the leading caused of injury and death within the united states. So it was expected that our Current Administration would act on this issue and in october our current president declared the Opioid Crisis a Public Health emergency. And in november, trumps commission on the Opioid Crisis released its final report with the recommendations on how to handle this and so it had 56 different recommendations. Last week the House Committee started having hearings on this report and then the white house appointed Kellyanne Conway to lead this effort. So the Public HealthEmergency Declaration doesnt provide any direct funding to d. P. H. But it does open up some avenues to increase addiction treatments and this is specifically around eliminating the i. M. D. Exclusion so that we would be able to get reimbursement for hospital stays through medicare and also it would increase the access for medical assisted treatment. And the last item that ill present on is our 340b drug discount program. This is a federal program that requires drug manufacturers to provide outpatient drugs to Eligible HealthCare Organizations at reduced prices. So its a safety net hospitals such as s. F. General buy these drugs at a discount from pharmaceutical companies and then theyll reimbus for those services from medicare and extend those savings through patient care. In november, it was announced, a final rule that cut the 340b payments, a lawsuit has been filed by hospital groups to prevent this from happening and two house of representatives have introduced a bill that would also prevent this cut. This final rule would impact would reduce the programs revenue by about 28 so its 1. 6 billion nationwide and the impact to d. P. H. Would have been about half a Million Dollars. So those are some of the federal policies that are potentially impacting d. P. H. And im happy to answer any questions at this time. Supervisor cohen thank you, cynthia, i appreciate the very thorough and important update. Colleagues, any questions at this time . No . Seeing no questions. One question. Supervisor fewer seeing that this could really supervisor fewer seeing that this could effect a lot of people in San Francisco, what are our plans do we have any plans if these were to go through . And how do we intend to backfill some of these services or do we . So a lot of the federal policy changes would then impact the state so i think that our first line of defense is really working with the state legislation to see how we can mitigate the local impact. So i think that a lot of these issues are really fluid and theyre changing daybyday and so we dont have a formalized plan, but a lot of these programs go through medica well other thal, sowell see legislad on a state level to combat these issues at a federal level. Supervisor fewer thank you very much. Supervisor cohen thank yo you. Heavy subject matter. Thank you. Colleagues any other questions and we can go to Public Comments on items one and two. Ladies and gentlemen, if theres anyone that like to speak on items one por or two, come on u. Hello, im dina lawn, the Vice President of internal affairs for the San Francisco clinic consortium. As cynthia mentioned were a coalition of the nonprofit coalitions and the northeast medical services, etc. I made an error in supplying information to d. P. H. And i want to correct that and to talk briefly about the impact of the Health Centers fund not being renewed. I had originally given an estimate of 5 million to 10 million and in doing that i made an error because i didnt realize that the same fund had contained funding for our health care for the Homeless Program. So the San FranciscoCommunity Clinic consortium is the recipient for San Francisco of the health care for the homeless funds and we then subgrant those funds to several of our clinics and to several of the d. P. H. Clinics, and we also run a very effective outreach van that goes around the city to certain places and provides kind of urgent care but more importantly a connection to primary care for any Homeless People that we can convince that they want to be welcomed into one of our clinics or the d. P. H. Clinics and enroll in whatever they are eligible for and get health care. We dont usually come before you very much and the reason for that is that of all of the nonprofit Community Clinics only 4 of our funding comes from the county and the majority is from the state and the federal government. This money is critically important for our clinics and especially for our health care for the Homeless Program and it will have an impact on the entire city so we want to make sure, a, that we corrected the number which should be 14. 4 million and make it clear that this is absolutely crucial and we have communicated with nancy plohse and harris and finestein are all onboard and were hoping that the res liewgdz to we hope for a res liewgdz inresolution on this. Supervisor cohen thank you, i appreciate your perspective and thank you for sharing it. Any other member of the public that would like to share . Seeing none, Public Comment is closed and