So those have increased significantly, and thats really due to the to the ihss moe going up. The the Health Benefits piece is fairly oh, excuse me, ive jumped to the wrong one. Pardon me. So if we look at this one, what well see is weve got a large growth of the maintenance of effort, there we go, from 94. 6 to 117. 8, and then, we have a small increase in the office of ageing. This is due to additional dignity fund. We have a fairly stable ihss Public Authority payment. This is the Health Benefits payment, which has stayed fairly steady. And then, the other areas of the budget are really pretty much staying roughly where they are, just kind of basic inflation that adds little bits here and there. Commissioner loo . Commissioner loo i have a question. The question is the ihss consortium, the program in 1819 compared with 1718 is reduced by 25 . Yes, and so this is the item that was the error that i mentioned, so we would add 4. 5 million to the 1819 number. And just to say it again, and what happens when we put this together, was we projected we included the 1718 projection. Now whats going to happen between now and 1819 is we will be implementing the tiered wage concept within home bridge, and that will increase the wage for the home care workers. Whats happened within contract mode and shireen spoke to this before in her opening remarks, was that as we as the gap between the home bridge wage and the minimum wage went to zero, it became harder and harder for home bridge to attract and retain workers, and the number of workers started to decline on the home bridge staff, and therefore, the no number of hours of home bridge needed to provide began to decline. I dont mean to oversimplify it because it involves training, it involves other things to professionalalize t professionalize the job, but its to make it easier for home bridge to attract and retain workers. We believe it will succeed, and as it succeeds, the size of the workforce will become larger, and home bridge will come closer to deliver the number of hours that the ihss asks it to deliver. So as that happens, the costs will go up. If the if the 22. 7 is a good estimate of where we are this fiscal year, which we think it is, the higher number of 27. 2 is our estimate of what will happen at we raise the wages of the home care workers and as we begin to have more home care workers and can deliver more hours of service. So the number in the current fiscal year, 29. 2, is a number that was developed before the labor problem started really manifesting themselves, and so we are, obviously, dramatically underspending that budget in the current year. Does that answer the question . Commissioner loo not really. I have to think about it. Okay. I mean, i think the key is we had budgeted in 1718 at a level of service we had hoped to be able to buy from home bridge. Because of home bridges labor difficulties difficulties in the sense of not being able to attract and retain workers, we have made changes, changes in a way that we hope will significantly allow them to provide more hours, so instead of allowing them to provide this many hours of service, were allowing them to provide 27. 2 million hours of services. [ inaudible ] they, like most of our contractors are reimbursed for actual costs up to a not to exceed amount. You know, because you see lot ofs of you budgets for daas contracts, between our program office, our Contract Office and the provider, an agreement is made on what the budget will look like, and thats whats in fact presented to you. So so we pay them for their costs. One of the things thats happened over the last year, which is not a good thing, as far as were concerned, is the cost of an hour of service had gone up quite a bit, because the number of workers delivering the services has gone down in number, but, you know, most of the infrastructure of the organization has stayed in place. So one of the things that having additional workers will do is it will it will stablize the cost of an hour of service. Commissioner loo all right. Thank you. Okay. Now to the slide i started talking about wrongly before. So character is our word for a type of service, and as you can see, the aid payments character grew substantially. This is mainly as a result of the increase in the ihss moe. There are some smaller growth in contract services, which includes mainly dignity fund and and clfsupported services, but thats mainly whats changing here. So in coming up with our budget submission, we actually went through revenue projections for all of the parts of the human servic services agency, including daas. There are a number of areas where it looks like revenues are going down, in our cal mesh and cal works programs, and others where its going up. For example, our medical eligiblity programs, these are entirely an artifact of whats happening in the state budget, so Cal Fresh Program is shrinking budgetarily because budgets are shrinking stayed wide, which is the sign of a good economy. Fewer people are eligible. Thats true for cal works, as well, which is tied to employment and unemployment rates. The medical program is one that grew tremendously during the early years of the implementation of the Affordable Care act and is more stable now but at a much higher level, and the state is catching up in terms of its eligiblity budget. We had assigned by the Mayors Office, a 1. 3 million general Fund Reduction in the budget year, and twice that, a 2. 6 million are you duction in the budget year plus one, or fiscal year 1920. As you may know, the ihss grew a lot during the recovery. Were still catching up on our hiring, and we think we can cover the gap in the budget year with at least salary saving, so we are not proposing any reductions in program. And i am i am not thinking that in order to meet this, i will need to put a hiring freeze in place. Ill let you know that if that turns out to be wrong, but im not anticipating that we will. So so basically, we have also been asked by the Mayors Office to propose no new fte, which we have not done here. So ihss maintenance of effort, and this is ofshl tis obviousle there are several big cost increases. One is under the new law, the rate at which each countys ihss moe increases is governed by an inflation factor. Under the old program, the inflation factor was 3. 5 a year. Going from 1718 to 1819, its going to climb by 5 , and going from 1819 to 1920, its going to climb to 7 , where its going to stay. 7 is a very rapid rate of growth, and as you can see, adds 5. 6 million in the first year of the project. The minimum wage increase if you remember, San Francisco has its own city minimum wage, and it will be going to 15 an hour on july 1st of this year. The minimum wage increase is something that triggers a change in the ihss moe because the cost of paying the wages go up, and under the state law now in effect, the county pays a share of that. So our estimate of the impact of the 1819 increase is 7. 8 million. And then after 1819, we will grow by inflation. Our minimum wage will grow by the cpi in each year. Obviously, that will depend on what the cpi is, but were assuming it will be somewhere between 35 and 50 cents a year Going Forward. So another 7 million Going Forward in the second year. And then one of the things thats an artifact of the current state law is the state proposed a great increase in the maintenance of effort payment on counties as a whole. In total, it was about 592 million shared between all counties, but the legislation sb90 included a large state general fund offset in the first year, 400 million. In the second year, which is 1819, the state offset is 330 million, so counties have to pick up an additional 70 million of cost among them. And then in the third year and Going Forward, the state offset will drop to 150 million, so thatll be another big increase for counties to cover, which is part of the reasons is becomes unsustainable after two years. So all those things together in the budget year increased costs by 18. 7 million, and then a further 25. 2 million in the second year. Excuse me. Yeah. In the druktory memo, you mentioned infligsa mentioned. [ inaudible ] so in developing its proposal, the state attempted to look at the way the total fund costs of the program were changing, and so if you think about the drivers of the cost of the ihss program, you can split them out different ways, but one way to look at it is theres a major cost component, wages for ihss workers, Health Benefit costs for ihss workers, and sort of the dollar per hour side, and then, the number of clien clients served by the program and the average number of hours permonth a clients received. And so wages are climbing up. Health benefit costs are, in most counties, a number to medical inflation. Certainly, they are in this county. The number of clients is climbing, and the number of hours perclient is climbing, although probably the slowest of all of those. So the state has argued that the total fund costs of the program are increasing at a number closer to 7 than the 3. 5 that was in the previous ihss demolaw. So the 5 in the budget year is really a phasein of that 7 inflation factor. Thats how the state got to that . So in essence, its primarily being driven by increased caseload and increased needs as opposed to inflation as we normally think of it because milk has gone up at the supermarket. Its primarily more caseload and more hours that the individuals need. Thats a very big part of the driver, yeah. And you know, this is this is not something that we wouldnt expect, right . We, like every other state in the nation, have an ageing population. More folks with serious disabilities are living in the community, obviously oh, no, that makes sense. I was just measuring inflation the way that general economyists measure inflation. Oh, yes. Okay. Residential care for the elderly. One of the things that happens in our budget process, we fund things in our target, and there are some things that we propose to the mayor outside of our target, and this proposal for rcf for the elderly is something that is in the latter group. Its outside of our target, so we would be asking the mayor to come up with an additional 1. 1 million in the budget year and 1. 2 million in the second year. And i just want to be clear about that. Thats got kind of a different status from some of the other thipgs weve thin things we talked about. Basically, as you know, our cfes are communitybased karen at this times that provide a staff staff, a place to live, and personal assistance care for people who need it. One of the phenomena that i think everyone is aware of is that, you know, as as peoples needs go up, some people can continue to live successfully in the community with support like ihss; some people need a higher level of care and more of a 24hour environment, and the goal of the proposal is to begin to move us into this area to be able to provide some emergency placements and then to provide some what we call patches to to support the ability of individuals lowincome individuals to be able to continue to stay in San Francisco but in an rcfe environment as opposed to an inhome environment. You want to add . Thats the basis. Yeah. I mean the only thing id add is we really see a need for this with the dementia population, and we dont have a lot of resources for them, so were hoping this helps us we do this through our contract, but wed really be able to help these few individuals who would be able to utilize these beds. And arent okay. Commissioner wallenberg, please. Just had a quick question. So the proposed enhancement is the three proposed beds and 20 longterm beds, so what is the baseline that were starting from . Well right now, we dont really have access we have some access to place in some of our programs, but we just show theres a real shortage here, so Community Living fund has some. We have, like, i think two emergency beds for adult protective services, but thats just simply not enough, and were really seeing that sometimes we cant adequately provide services for people because their living situation means that you know, isnt enough, and they need care ongoing care that they cant get at home. So i think, you know, were just starting were hoping that were going to build this into our budget and were hoping that the mayor will be interested in this, but were also just trying to elevate the conversation, so i think if it doesnt happen in this budget, were really trying to elevate the conversation. Weve had a lot of conversations also about looking at waivers, going back to the state and getting getting more of the conversation to happen at the state level, but its really here for the purpose of creating conversation, and if were able to get it into the budget to be able to serve these People Better who will be the fortunate ones to access it, itll allow us to just kind of continue that conversation and see where we get with it. So i mean, i think the difference here is weve had a tiny bit of emergency access in the program already. We havent really come to terms with a program that would be more of a longterm program that would say, you know, someone is not going to just step into an rcfe for a shortterm stablization thing, but thats where they would live Going Forward. The longterm trend, however is for fewer and fewer rcfes in San Francisco, and so is there how is there anything that we can anything that we can do about that, or are we going to be placing people outside of the city . So i think there so theres been a lot of work done on this issue, and i think most recently, both the you cute Care Collaborative has done a lot of studying the beds, the loss of beds, not just in San Francisco but the region in general, and will be making some recommendations to the Health Commission and to the Hospital Council about what could kind of what are some directions that we could go to help preserve what we have, and certainly, there has been talk at the city about how to about some different ways that we could incentivize people either keeping their businesses or either starting new ones, and its still kind of a nascient conversation, but theres not a plan that says yes, the citys adopted there, but were getting there, and eventually we will have a plan that says this is what the citys good going to do about that. One thing i think we agree on is we dont want to have a policy of sending old people out of the city because they need something that we dont have, or even worse, sending them out of our general region, so i think theres a lot of energy in this conversation or goodwill. But its going to take a lot of effort and some putting some new resources in or incentivizing it in some way that we dont have it yet. Thank you. Commissioner wallenberg. Yeah, and that kind of leads me to my question, what are the current numbers in terms of needs for actual individuals and then what that looks like. And then, i guess i had kind of a more nitpicky question in terms of what any given times means the beds being the three emergency beds and the 20 longterm beds. That phrasing was meant to me we could sustain an average of 20 folks for this amount of money. Yeah. And i think your other question, we could get you that information because that research has been done, but it would mean bringing it in, maybe making a special report to you. I think it and we did talk about this also, is the post acute Care Collaborative, once they go back to the Health Commission, maybe we could ask that that report be also brought to this commission. Might be helpful. Yeah, we could do that. That would be fantastic. Mr. Chair, just a point of curiousity as were discussing this. I know that the church up on laguna honda, received a part of the stipulations, and part of the residents there would be ageing seniors in transition. Does that show up in our budget or is it hsa or is it department of homelessness . Its not in ours. Okay. We can find out. It just would be curious to see who would have that. I have a question. Commissioner loo . Commissioner loo we were talking about seeking new money, and we all know that budgets are really kind of tight. What happens if we dont get the money . That means we dont we dont have the full grant or is the agency making efforts to find other sources. So if we dont get the money, we will not have the money, but we will continue the conversation, well continue looking for other avenues for this. Like i said, i mean, one of the things that we a lot of the conversations that were also happening at the state level, because this is a statewide problem, so we will be hopeful that maybe some money will materialize there or figure out a way to expand the current waiver or do a different waiver for San Francisco. There are a lot of different possibilities, but really, this is to to elevate the conversation here and were very hopeful that itll happen. Other states have put in place more robust Residential Care waivers than we have in california. They probably dont face the kind of housing and infrastructure costs that we face in San Francisco, so you know, theres a lot of work that needs to be done on developing this level of care. Commissioner lang . Commissioner lang i actually like this notion a lot, and i have a question. Theres something we can do as a commission in terms of advocating and pushing this before the mayor to have Something Like this included . Can we sort of put together an advocacy plan in relationship to these new dollars . Can we help . Will with, thank you. The first step would be approving the budget submission. Yeah. Were going to get there, too. Were going to get there, too. I think thats the biggest part is really just approving it and saying youve thoroughly vetted this and you know its important because of what youre seeing because youre the eyes and ears on the ground for older adults and people with disabilities, and then, there might be something later where if people have questions about it and the value of it for the community, that there might be an opportunity for you to voice that. Okay. Well, in relationship to sort of approving this budget and finding some do