Good morning, light to call the order. The Board of Supervisors Health Committee for Monday, September the 23rd. First item that we have is informational item, children and youth health community. Yeah, that one today, I know one was canceled. I'm not sure which one, that might have been it. And if so, then we'll move on to the Alameda County Health System, Squirtlely Financial and Operational Update. Oh, we do Supervisor have the youth presentation in the health series for you. Okay, and what is that? Okay, thank you. So, good morning, Supervisors. Today we have a continuation in our health series. It's going to be presented by Sandy Galvez, Julia Raphman and Lisa Erickson from Alameda County Health. And if you could go to the next slide, please Tisa. As a reminder, this is one in a series of special health committee meetings where we dive deeply into subpopulations within Alameda County to examine health and health status. So we've been looking at the health status of people by race ethnicity, gender, disabilities, and age, and today our spotlight is on youth. Go to the next slide, please, Tisa. So today we're going to be talking about children and youth. And as you'll see, children and youth sometimes do directly experience health challenges, including early death, but oftentimes what we see in this population are social conditions that are predictors of health issues that present later in life. Our data indicate the following key points regarding the health status of youth in Alameda County. Historical and modern day policies have shaped inequities in poverty affecting African-American and Black, Pacific Islander, Hispanic, Latinx, and American Indian Alaska Native youth. Childhood poverty often translates into food and housing insecurity, adverse childhood experiences, and worse educational outcomes. There are stark inequities in the mortality for youth under 25 in Alameda County, with African-American black youth mortality rates more than four times higher that of Asian youth who have the lowest mortality rate. Homicide is the leading cause of death for people under 25. Levels of mental distress have increased in our especially high among LGBTQ plus and Pacific Islander youth. We see success in our youth services and programs that are collaborations across the agency and with community partners, building on resiliency and strengths of youth, families, cultures, and communities at every stage of life. So the key takeaway for you for this morning's presentation is that improving youth health warrants a focus on primary prevention strategies that address structural policy and institutional drivers of health and deep partnership in community. So at this point I will turn it over to our team to take over the presentation. Good morning supervisors. As with previous presentations, we have given you in the series. We'll start off with sharing some historic and demographic information to provide context for the health outcomes that we see today. And for youth we'll be beginning with the 40s. The post-war period of the 40s and 50s, oops, can you think? The post-war period of the 40s and 50s brought the baby boom and strong economic growth, particularly for the white working class residents of our county. Many were able to purchase homes and new suburbs like San Leandro and Hayward, but most residents of color were locked out of that opportunity through racist practices like red lining and racially restricted covenants which have covered in previous presentations. The social movements of the 60s led to expanded anti-poverty and youth programs, funding for education, nutritional supports, and health care for families with children. And locally, the Black Panthers, the National Welfare Rights Organization, and the Coalition to Fight Infant Mortality led movements to improve outcomes for low-income families of color in Elimita County. The 70s brought a decline in manufacturing, food processing, and other blue color jobs in the East Bay with subsequent unemployment and wages deterioration, a service sector jobs became prevalent. Education funding and funding for local services were cartel substantially by the passage of Proposition 13 in 1978. This led to an overall decline in the quality of public education as well as a decline in public services. At the end of the Vietnam War, significant numbers of Southeast Asian refugees settled in Elameda County, adding to an already diverse youth population. The 80s and 90s were carried to rise by a continued backlash against the programs of the 60s, with reductions in the social safety net through a welfare reform and the federal war on drugs, which disproportionately affected youth of color. Youth of color were often demonized by political leaders and the media. And the tolerance policies in schools led to disproportionate expulsions of youth of color. However, the new century brought the beginnings of some improvements for youth in our county. Several local tax measures increased funding for schools and preschools while 2013 statewide local control funding formula restored some of the school funding lost to prop 13 and focused on the highest need populations. Gradually, California's youth prison system was dismantled that after over 100 years of reported neglect and abuse. In 2023, it closed the division of juvenile justice, which was formerly known as the California Youth Authority. New community and form violence prevention strategies began to bear fruit as violence inclined in the decade prior to the pandemic. However, first the foreclosure crisis and then the housing crisis overall brought renewed economic strength to youth and families. Immigration from Latin America, particularly Central America, increased during this period and often included on accompanied youth. And then the pandemic, as we all know, brought major disruptions to schools and youth services throughout our county with large impacts on mental and behavioral health for youth. Next slide, please. So just to summarize our history policy choices in the 40s, 50s and 60s led to disinvestment, residential segregation, and urban economic decline. And in the 80s and 90s, policy responses to that decline often tended towards punishment and coercion to change behaviors instead of underlying conditions. We saw the war on drugs, well for reform and mass incarceration. And as a result, many youth of color experience childhoods of poverty, intergenerational trauma and criminalization rather than needed supports. In our county and state-wide, we began to break that cycle in the past two decades with summary investment in education, preschool and youth programming, and culturally relevant and acid-based parenting support programs and less reliance on criminalization and punishment. New challenges of a written, a risen and old ones remain most notably the housing crisis and the related economic pressures, the impacts of the pandemic isolation, the continued legacy of mass incarceration and intergenerational trauma and poverty. And throughout today's presentation, you will see the evidence both of our progress and of the challenges that remain as we strive to create healthy beginnings for all of our county's children and youth. Next slide, please. The figure before you is from the Brookings Institute and it depicts per person spending of federal, state, and local funding by age groups in the US in 2015. Nationally, much more of our government funding goes to supporting people in older ages than at younger ones. However, investments in childhood and youth may have more impacts as those investments affect lifelong trajectories of health and well-being. Next slide, please. 30% of Alameda County's population is under the age of 25, which is very similar to surrounding counties. The youth population has a grazier proportion of Latinos than does the population overall and a smaller proportion of youth which are white relative to the general population. The same proportion fits for the rest of the groups. Next slide please. I'm so now I'll be covering some social determinants of health data. This slide displays the disparity rates for children and youth under 18 in our county. African-American rate is nearly 10 times that of whites and Pacific Islanders and Latino populations about 5 times that of whites. African American, Latino, Pacific Islander, and Native American youth are also more likely to experience housing and food insecurity. These conditions in themselves are predictors of poor health outcomes and also creates stress that contribute to family violence and other adverse childhood outcomes. Next slide. This is a very striking slide. The Alameda County Office of Education reports that the families of 4,771 school children were homeless in 2023. Defined is lacking of fixed regular and adequate nine time residents. 64% of these children are Latino, while Latino children only make up 35% of school enrollment, 20% are African-American, whereas 8% of all students are African-American. Another measure, our county's point in time count, found 926 young adults ages 18 to 24. Our Office of Homeless Solutions reports that 63% of homeless transition age youth are African-American and 42% are LGBTQ identified and 43% are experiencing mental health issues. Next slide, please. Here we see rates of non-completion of high school disaggregated by race, gender, and other statuses for the school year 2022-23. Non-completion rates are highest among students in foster care at 31.1%, homeless students at just over 30% and students who are English learners at 19.3%. 12.8% of Latino students did not complete high school, followed closely by Pacific Islanders at 12.7%. African American students and American Indian and Alaska Native students also did not complete high school at higher rates than students overall. The race and ethnicity disparities for high completion or for high school completion are stark, only 3.7 of white students and 2.2% of Asian students failed to complete high school. An educational attainment is a very strong predictor of health across the life course. Next slide please. Lastly, we see that a high proportion of our counties, American Indian, Alaska Native, Black and Latino, Transition Youth are disengaged, meaning that they're neither in school nor employed, at much higher rates than white or Asian Transition Age youth. Transition Age youth who are disengaged from school or worker at high risk of long-term poverty, violence and homelessness. Next slide please. The percent of youth without a use or source of health care rose from 19.2% in 2017 to 16.5% in 2022, which is an increase of 79%. And in 2020, the California Health Care Foundation estimated that over 120,000 people in Alameda County live in areas with shortages of primary care providers. Our programs report that lack of access to a pediatric care provider is a major contributor to developmental delays and adverse health outcomes in young children. Next slide please. Lastly, this slide displays the numbers and percent of Alameda County children who qualify for subsidized child care that are receiving that care versus those who are not. The child on the left displays unmeant need for toddlers and infants while the slide on the right displays the preschool unmet need. Early care and education are high predictors of academic success, a major social determinant of health. Voters in our county approved measure C, which provides funding for some, but not all of this gap. I will now turn the presentation over to my colleague, Julia Rafeman, who will discuss health indicators. Good morning. I'm Julia Rafeman. I'm the director of Community Assessment Planning and Evaluation for the Elmina County Public Health Department, and it's a privilege to be here with you this morning, presenting on the health of youth in our county. Out of my presentation, I'll share a couple of points. Some of the data that we'll see show really stark and upsetting disparities in the health and mortality of youth in our county. We take very seriously these data and Alameda County's commitment to improving health and reducing health inequities in the county. We also see some data that give us optimism and in particular we see that policies have made a difference. We see that strengthening immunization policies in California has led to an increase in immunization rates here in Alameda County as well as across the state. Next slide please. This figure depicts the leading causes of mortality for use under age 25 and Alameda County by age group. You can see that the leading causes of mortality for youth under 25 in the county are homicide, conditions originating in the perinatal period, motor vehicle crashes, congenital conditions, and suicide. Next slide please. This figure depicts racial and ethnic disparities and mortality under the age of 25. These data are from 2005 to 2021. And unfortunately, we see that there are very large inequities in mortality under the age of 25 with African-American and Black youth. More than four times more likely to die before the age of 25 than Asian youth, who have the lowest rate of mortality under age 25 in Alameda County. Next slide please. This figure depicts trends in homicide in Alameda County from 2006, 2007 to 2020, 2021, overall and by age group. You can see that youth age 19 to 25 have been disproportionately affected by homicide throughout the time period and have been affected by the increase in homicide that we've seen in the first two years of the COVID-19 pandemic 2020 and 2021. Next slide please. This figure depicts trends in suicide rates by age group for youth under age 25 So you can see that youth age 19 to 25 are more likely to have died by suicide than youth under age 19 The trends have stayed relatively consistent over time that there has been a 10% increase for youth age 19 to 25 from 2021 use age 19 to 25 from 2007 to 2021. While we don't see a spike in suicide that happened in the first two years of the COVID pandemic, we do see spikes in mental distress that affected youth in the county during that time period. And we also note that mortality data don't include sexual orientation or gender identity. But when we have data on suicide attempts and suicidal ideation, we see the LGBTQ youth are disproportionately affected by suicidal ideation and attempts as our Pacific Islander youth in the county. Next slide, please. This figure depicts pens in the fully-unmunized kindergarteners at school entry from 2009, 2010 to 2324. And you can see that after the California State Policy Senate Bill 277 eliminated non-medical exemptions from school immunization requirements. There was an increase in the percent of kindergartners fully immunized at school entry. The percent of kindergartners who weren't fully immunized actually decreased by 64% here in Alameda County. And these trends were relatively consistent and high until the COVID-19 pandemic, when many children were not in school and the immunization rates declined. We have seen some increase again following the pandemic, though not too as high a level as prior to the pandemic. and the community is a community that is a community that is a community that is a community that is a community that is a community that is a community that is a community that is a community that is a community that is a community that is a community that is a community that is a community that is a community that is a community that is a community that is a community that is a community that is a community that is a community that is a community that is a community Next slide please. This figure depicts the percent of children under age six with elevated blood-led levels in California and in Alameda County And unfortunately we see that there are elevated levels of Elevated rates of high blood-led levels among youth in Alameda County relative to the state of California Young children are at high risk of lead poisoning because their nervous systems and organs are still developing because of hand-to-mouth behaviors that can expose children to lead in their environment. Lead exposure can cause serious acute health effects including death while lower levels of lead affect the nervous system and cognition, causing learning disabilities. Both state and federal regulations require that children served by Medicaid are screened at ages 12 and 24 months and up to six years if not previously tested. Although there is this requirement for children on MediCal, only 44% of California children on MediCal have blood-led level screening at 12 months and only 35% have screening at 24 months. There are also racial and ethnic disparities in blood-blood levels screening among children on MediCal. The Community Development Agency Healthy Homes Program conducts investigations into sources of lead for children with elevated blood-blood levels. These investigations typically focus on the home environment. Well, they're not complete data on sources of lead exposure, lead paint in homes, and lead in spices are makeup, focus on the home environment. Well, they're not complete data on sources of lead exposure, lead paint in homes and lead in spices or makeup or leading causes of elevated blood-led levels. Let lead in makeup and spices particularly effects Afghan and Asian Indian populations in Alameda County. The Oakland Unified School District recently detected high levels of lead in water in some school facilities, highlighting that there can be many potential sources of lead exposure for children. Next slide, please. Finally, we see that there are racial and ethnic disparities in overweight and obesity among adolescents or among fifth graders in Alameda County. And we see that structural drivers of like access to healthy foods and exercise can affect overweight in obesity and inequities and overweight in obesity in the county. We see specific islander populations and Latinx populations and black and African-American populations disproportionately affected by childhood obesity and being overweight relative to Asian and white populations who are less affected. And this is particularly important because heart disease is the leading cause of mortality in middle and older age in Elimita County and childhood is a key time for establishing healthy weight and exercise trajectories. Next slide, please. Which I'll turn it over to my colleague, Lisa Erickson. Good morning. And thanks for having us. I'm just going to talk a little bit about our programs and services around children and youth as well as our policies recommendations. Next slide please. So to the right you'll see that these are some of the culturally affirming approaches that you've been hearing about throughout all of the presentations that we've been doing and to the left or some of the age specific approaches. The kind of best practices around serving children and youth. Just to summarize, ensuring that their basic needs are met, centering the whole child, centering the whole family within the cultural context and community, making sure that we're breaking down silos. So really working together across agencies to make sure that families are getting their comprehensive needs met within communities and within their family. And strengthening supports that are offered to schools within school and to transitional age youth and lastly listening to youth. So including their voice and the programs that we develop and in the policies that affect the most. Next slide please. And now these are just some examples of some of the or sampling of some of the youth and family friendly programs. One, I won't go through all of them because we don't have time today, but one initiative that I wanted to highlight is the Children and Youth Behavioral Health Initiative, which is a $4.5 billion initiative at the state level, and we've been doing a lot of work at the county coordinating with other agencies to make sure that this initiative is being implemented within our schools. Effectively, we have a school health steering committee that we're partnering with Alameda County Office of Education to hold. And the main goal of this initiative is to increase behavioral health programs within our school districts throughout Alameda County. And also just to note that at the Alameda County Public Health Department just received a grant from this initiative to help support their mental health consultation in their home visiting programs. So that's some exciting news that we got last week. Another program that I'll highlight, it's actually on the next slide, is around the youth voice. So at Reach Ashland Youth Center, we're piloting a program called Youth Power Sharing, and we're involving youth in co-producing, designing programs, making decisions, and sharing youth, I mean sharing that power with the adults that work at Reach. And it's been a really exciting program. The youth are very engaged, and they've been really helping to kind of design everything that's happening at reach and you know govern the overall center. And also the Youth Advisory Board of Office of Homeless Coordination is also a promising practice where they're leading the Youth Homeless Demonstration Program grant and they have a the the app with what's called the app which the youth advisory board and it includes its youth run and it's helping to manage that grant. And it's a great that's fine. Next slide. And on to some of the policy recommendations. The first one is what I mentioned in some of the approaches, which is making sure that we invest in basic needs. As you saw in the data, child poverty has a real impact on health. So continuing to invest in economic supports like universal basic income, the expanded child tax credit, and tenant protections and affordable housing. And not just having the resources available, but making sure that they have the children, youth and families have access to resource navigation and care coordination. And making sure that this resource navigation and care coordination is coordinated within our highest need neighborhoods of color. So funding place-based comprehensive youth development approaches and those neighborhoods with the highest need. And again, we want to make sure that the youth voice, that we're listening to youth voice, and they're really involved in our county decision-making processes and our needs assessments and planning processes. And increasing investments in behavioral health and housing supports, especially for queer youth of color. Next slide please. Also investing in age-specific interventions, so across the entire continuum from birth all the way into transitional age youth. One example is continuing to expand the investments in early care and education. I know all of you know about measure C. So making sure that we're partnering with first five who's administering measure C to make sure that this very exciting initiative is implemented really, really well and families and know about measure C in the opportunities across the county. Also supporting blood level screening for children under six and increasing investments in comprehensive approaches for higher need transitional age youth that combine housing career preparation and case management, and expanding residential treatment for supportive housing for older youth with severe psychiatric substance use disorders and other intensive needs such as human trafficking survivors. And also expanding the healthcare workforce. So more efforts to increase pediatrician participation in Medi-Cal, and including further reimbursement rate increases for pediatric care with Medi-Cal. Also increasing the funding for healthcare, career workforce development programming. So more health career pathways, work-based learning for youth, and paid internship opportunities. And that was back to the Children on Youth Behavioral Health Initiative. There's several workforce programs within that initiative that we're actually trying to partner around right now as an example. Next slide please. Oh, that might be the last one. No? There's one more. Oh, there is one more. Thank you very much. Thank you very much for the presentation. Supervisor Tanya. Thank you, Chair Carson. Really appreciate the presentation. And I know our office in particular with the work that the supervisor, Lake Surveyser, and Mama Chan had started in looking at a systems coordination between the city and the county and the school district and then obviously with the first five initiatives through the measure C funding. Those are very key. I did have some questions. Probably more helped me understand from a historical perspective and the alignment with county programs. So on your slides, 18 and 19, you show that there's a disproportionate, particularly on 18, the mortality rates for youth under 25, particularly African American youth. It's 4.3 times and most of it from your prior slides is from results is from homicides. And when I look at slide 19, you know, starting in 2006, I presume there were county programs that were in place and that trend has actually gone down in terms of homicide rates until 2019. Then it's like heading and heading back up. And so can you help me understand what programs were put in place to help bring that trend down and then what happened in 2019 and 2020 besides the pandemic because the issues around gun violence is something that I know the county has been trying to work very closely particularly with the Department of Violence Prevention in the city of Oakland and trying to understand when we declared it as a public health crisis, what tools were available because of that declaration. Thank you. This important question, and I think really heartbreaking data that are important to address and improve over time. What we see based on the data is that there was a spike in homicide in 2006, and then a decline that is a relatively unusual decline. Most of the time we go across the state and across the United States, we see that the data were relatively consistent over time and that that decline is unusual. And we do think that community violence intervention effort played a role in contributing to that decline. And the Alameda County was really a leader in that. We also saw that when the pandemic disrupted, because so many social disruptions and in the climate of so many structural inequities, like we see in the poverty data, that leaves us really at risk of seeing what we did see, which was an increase in homicide. And we saw a larger increase in homicide here in Alameda County than in California in the United States, which also experienced some increase, but not as it is to a large extent. So there was structural inequities that we have with poverty. It'll leave us vulnerable to something like that. And the disruption of community violence intervention efforts, school, work, all of that likely contributed to the increase across the country and California and even more so here in the county. I'm really glad to have Dr. Ayala here to help speak to what we're doing in the county as well. Thank you Dr. Rayfman. My name is George Ayala. I'm the deputy director of the Alameda County Public Health Department. Thank you supervisors for this opportunity. Supervisor Tam, I really appreciated your question. And the only things I would add is that you might know that the health department establishes recently an office of violence prevention. And it is a direct kind of response to some of the increases, the uptick and homicides that we have seen in our communities. That office, along with the office of the increases, the uptick and homicides that we have seen in our communities. That office, along with the Office of the Director and the Health Department, have been working in coordination with the City of Oakland and with District Attorney's Office to your earlier point because there's an interest in ensuring that whatever our responses might be, they're coordinated. The Office of Violence Prevention is interested in supporting community-led, HIV, sorry, violence prevention initiatives, and we issued a solicitation inviting proposals as such. And we're looking at those proposals. We're gonna look at those programs very, very carefully, and we plan to evaluate to really make some contribution in our knowledge base about what works and what we could be doing more. I could also just supplement Dr. Ayala's comments about the proposals that are coming in. So your board approved ARPA funding for the purpose of violence prevention. That RFP just closed very recently and Public Health Department is in the process of reviewing, having their selection committee review those proposals and make awards. So that should be coming to your board very soon. I also wanted to say that this was a blended funding RFP and it includes some funding that has come, that has been in the EMS agency for quite some time. The EMS agency has invested in programs that work in hospital emergency rooms to help disrupt violence at the point of injury. Thank you. I think one of the programs that Surveyser Brown had initiated through our funding was one of the recommendations you had on guaranteed basic income or universal income. Is there enough data to show that that is going to be helpful in addressing some of the structural inequities that you are pointing out in your presentation? And then what opportunities do we have to try to promote something like that longer term? Okay, yeah. Thank you for the questions that Professor Tam, we are participating in a kind of a multi-site study of guaranteed income program for a birthing people who are high risk for some of the inequities that we saw in the slide presentation today. We're doing it because earlier research have shown that guaranteed income programs improve birth outcomes, maternal outcomes, especially in early years, prenatally and then perinatally. So we're quite keen and leaned into understanding why that is. And we're excited about the introduction of that program. Let Dr. Rastman comment also. Thank you. I really appreciate your noticing that policy recommendation. I think it's an important one And what we see from the evidence is that universal basic income and expanded child tax credits have really made a very big difference where they've been implemented There actually is an urban institute study looking at I guaranteeed income for youth at risk of violence and they found that there was an association with reduced violence for young teen boys who were who are at risk of violence and they found that there was an association with reduced violence for young teen boys who were at risk of violence. And then we also see a lot of evidence from the expanded child tax credit which was implemented by the federal government during the COVID-19 pandemic that it actually brought child poverty to a record low and improved food and housing security for children. So we know that those kinds of policies can make a difference. That federal policy expired, so it's no longer an effect and we haven't seen a subsequent increase in poverty among children again. But I think it is helpful to know from that policy experience that it can make a big difference. Thank you. The last question I had pertains to pediatric care and outreach. I know we're going to be discussing this at Tomorrow's Board work session on the healthcare component or the pediatric component of measure C. And we, Troll, I know I have served on the Almead Alliance for Health and there's only so much that the alliance can do when it comes to pediatric outreach which is a part of your recommendations. Do you think that use of some of the measures C funding, particularly the healthcare component for pediatric outreach is something that can be integrated into the plans. I can speak to that some. I know that the meeting tomorrow is to discuss what the pediatric sub-account or the pediatric health care account in measure C can be used for. So that's part of what we'll be discussing tomorrow. So I would have to defer to County Council on how on their presentation, but I do believe that it's intended to support health care services in addition to trauma services, healthcare services, including specialty services for youth and young adults. That's very broad and broad. Yeah, yeah. I think it is. It does require planning for the use of those services as I understand, and consultation with certain named stakeholder groups, including physicians and others. Okay. I was specifically thinking about like, they helped me grow programs and that, but we'll wait till tomorrow. Thank you. Thank you. Thank you for the presentation. Appreciate it. I think it was fairly comprehensive in terms of its overview and kind of history and direction. A couple of questions. And I support kind of your suggestion and recommendations on how to approach various components of the presentation. So I want to underscore that and appreciate the work and the charts and the data that you presented. What we see very much movement in any of these areas today. And again this is I think you're hitting it out the ballpark in terms of causal factor structural approaches to it and all of that. But we see any measurable difference in almost each of these categories. Yeah, I think it's a really important question. And I think we do see these very longstanding disparities and longstanding need to reduce inequities and so many of the structural drivers that Sandy discussed inequities and poverty and the policies that really shaped those here in the county and nationally. You know, it has affected intergenerational wealth, you know, what babies are born into. And it's not something that has, you know, it's something that has been shaped by the whole history of the United States and slavery and redlining. And if we looked at the past decade, we would see that those inequities have played out over that whole time period. And certainly we work hard in the public health department to do everything we can to move the needle and things like, you know, it's good to see increases in immunization, right? And to see such an equitable COVID immunization response here in the county. But, you know, I think some of the structural inequities, like poverty really, are issues that take the whole of the county to think about how do we come together to address them. So what possibly can be done differently going forward, they kind of have a measurable movement in any of these categories. I mean, again, you hit it out the ballpark in terms of saying we got address housing issues, we have to address the educational issues, we have to address child care. All of those things I totally agree with. What actually needs to happen is better coordination across our public systems. Health department is one. But there are so many other agencies that we would need to be in coordination with and are in coordination with to really kind of influence and move the dial on some of these issues. The other thing that was implied by some of the slides that you saw today was the need for resource reallocation, right, societally. And I think that that really makes a difference. Every time we see, you know, things like guaranteed income or tax credits, we see upticks in the positive direction on any number of the health outcomes you saw today. It's why we begin all of these presentations in the way that we do because we understand it needs to be a multi-sectoral approach. And so we're doing everything that we can to kind of be in conversation with our partners and to really move policy in that direction. Tended I guess earlier this year, might have been April, and Atlanta National Conference, the National Black, elected officials, pretty good attendance. They had a number of workshops and panel discussions, which highlighted the exact same data, exact same outcomes. Realizing that over the span of the last 50 years, the numbers haven't moved at all, right? Attended not that as much as I wanted to because I was doing more county work, but I attended a portion of the congressional black caucus meeting two weeks ago in Washington, D.C., three, four days of overarching panel's discussions from that perspective, from individuals around the country, all have doctored their name and all of the other things that are important and same underscoring, same outcome, right? their name and all of the other things that are important and same underscoring, same outcome, right? One of the things that came out of the knob co-meeting was we do need these structures in place in order to execute, right? But as the various structures we have, especially the ones that are kind of connecting other departments that have important aspects and impact on this, keep filling as though what's being left out, not being funded, more challenging, are truly grassroots, big community-based organizations that don't have the administrative infrastructure that have the relationships and the credibility engaged in being able to connect with the various structures that are there that are important but are disconnected from the people that they are highlighting in all of these areas. The demographics change based on what part of the United States you may be in. If it's a higher population of Spanish-speaking individuals and it just switches from where Native American and African American numbers are. But, identically, all of these conditions are the same in terms of water, in terms of in terms of quality of housing and education and all of those things. But fundamentally, really think that, and from a way that it seems to be further removing a lot of the organizations that do that are part of lived experiences with individuals or saying they're frustrated and don't want to participate anymore with government because it just feeds itself. It becomes a monster unto itself and it doesn't really include in the individuals that they reference and continue to study. And again, this is not a negative to what we're doing. It's important, it's a part of what we have to do, but it is a major disconnect. disconnect and I guess the frustration within mainstream, within the African-American community is kind of further becoming disconnected from that. Including the faith-based groups that's coming out of the pandemic, they're even more pooled apart themselves. They haven't been able to get back their membership. They have a further disconnect. And so all of those groups are going more frustrated. Maybe some of that is why these numbers are being questioned about the upcoming election in terms of where people's energy is. Appreciate the presentation. Supervisor Carson, I'm wondering if I might ask Dr. Ayala to talk a little bit about our community coalitions because the neighborhoods that are in the populations that we saw had greatest disparities in the pandemic are the same ones that are challenged with many of these other health indicators that you've heard about today. And our public health department worked very closely with communities and small and large organizations alike in communities that had specific experience with the populations that have been experiencing the disparities and have been able to continue the coalition model through your board's allocation of ARPA funding and others to address just what you're talking about. So I might ask Dr. Ayala if he can talk about them a little bit. Thank you, Director Shalala. I'll start by saying that, you know, it's very clear to me that there is a community-led responses to any health issue. And in this case, we talk about COVID and other communicable diseases. Any response that it's community-led has a comparative advantage to responses that are government-led or responses that are strictly clinically led. And what I mean by that is that we really need to do what you're suggesting, which is reinvesting our communities, ensure communities have infrastructure and capacity to respond on their own behalf to the issues that they have defined as salient and important. And ideally, to respond in partnership with local officials, local health departments so that we do our job in making sure those responses are informed and capacitated. That's what we did in COVID as you know. We've responded by funding a series of coalitions six to begin with to help us with the COVID response. We added resources to add three more coalitions. So we now have nine coalitions. Those three additional coalitions respond to community resource navigation needs that we saw were critical during the COVID response. And so we have coalition set up to point people to the resources that they need and make it easy for those individuals to access those resources when they need them. In total, there are nearly 40 organizations involved in across those nine coalitions. And, you know, I think I speak for Director Wacken's Tart and my colleagues at AC Health that we are very invested and interested in continuing to support community-led responses, because I think those are the most effective. Thank you very much. And again, I appreciate the work that everybody's doing. Do we have anyone online? I have no speakers for this item. Okay. Thank you. We'll move on for this item. Okay. Thank you. We'll move on to information item number two, the Home Media County Health System, Corley Financial and Operation will update. Good morning, supervisors. Thank you for the opportunity to present. I'm joined today by my name is James Jackson. I'm the chief executive officer for the Alameda Health System. And I'm joined by Kim Miranda, who is our chief financial officer. And I would also note that our board chair is present. That's Mr. David Sine. So thank you for joining us today. Supervisors, with your indulgence, I'd like to suggest the following. We have three distinct presentations that we're prepared to offer today. I think the most pertinent one, the most timely one is pertaining to St. Rose. It's an update, it's informational, but I think that there's a lot happening and I'd really like for us to spend the lion's share of our time there and so with your indulgence I'd like to start with that presentation our subsequent presentations which are the finance report and the CEO report have been submitted for the record in time allowing Certainly we can present those but I I would ask your indulgence to let us start with the same rose presentation so Very good. Okay, so the clerk would not mind. Thank you. Appreciate you pivoting with this. So the St. Rose presentation today, we are gonna tag team. We'll move back and forth presenting on the various slides. I would start by acknowledging that this presentation is informational for the supervisors. There are factors that play that relate to the ability of the Alameda Health System to acquire St. Rose that are beyond the control of certainly the Alameda Health System and this Supervisory Board, but there are some elements that are within the sphere of the supervisors and those will come out during this presentation, but I do want to acknowledge again, this is an informational presentation. It's an update and we understand that there will be subsequent conversations in a decision-making form, which is not for today's purposes. So I just want to acknowledge that. Next slide, please. We believe strongly that there are significant synergies to be realized between St. Rose Hospital and the Alameda Health System, a number of them, which are articulated here. I will not read this slide to you, but I do wanna call out a few. In bullet number one, both of these organizations serve an essential role in providing the most vulnerable, care to the most vulnerable in Alameda County. And specifically, we feel that avoiding a closure of St. Rose Hospital will keep emergency cardiac and critical care access available to the central and south county specifically to the safety net population. Those who really do not have a lot of discretion, frankly, and where they choose to get their care. Moving down to bullet four, creating room to develop highly needed, gerocyiatric services in this community in Alameda County, mental health services we believe in there's documentation that they're the number one identified unmet community need in the St. Rose marketplace. And then the next bullet reimagining birthing to ensure patient care, quality and safety, labor and delivery services at the St. Rose Hospital. The planning birth rates across the county resulted in the low volume maternity service. The most recent period that we have data on St. Rose Hospital did 15 deliveries, and in the month prior to that they did 20. I would argue that qualitatively it's difficult to sustain a quality program that these birthing families deserve when you're doing one birth every day and a half to two days. So we are interested and excited about the idea of being able to reimagine how we can make sure that live births can continue to happen in the St. Rose community and the Hayward area in a way that provides adequate safety and quality for those patients. And then finally improving the supplemental funding and community support by remaining a private hospital. And I will next slide, please not turn to Kim or Annette. Thank you, thank you James. So this is an update. So all of the blue highlights are the items we have changed since we began pulling together the performance. So what you're looking at is the best information we have today. So as a reminder, we began with the ANOVA performance that were done last year. And then we have layered onto that, all of the things that we've identified or we believe should change once Alameda Health System takes over. So we're starting in a deficit position there. We have negative cash flow. One of the changes we had to make this time was to take down their net patient revenue. The volumes are not what they were when ANOVA projected it. They're worse. James just mentioned that we have fewer deliveries. There's fewer patient days. So all of that is driving down revenues. We did make a decision early on to keep the hospital private to allow for the highest amount of supplemental revenue. There's no change there. No change on the increase in managed medical rates. We believe we will be successful bringing in those additional funds. There are some expenses and changes to salaries and physicians and leadership. We've just kind of netted them there. No change in this presentation. We did discover that we can save some money on our tail insurance, so we've got a change there to actually reduce the cost. No changes in volume. We have intent to increase primary care presence in Hayward and have more access to the community, both in primary care and then through specialty care at the hospital. There's no change in that assumption. Subacute has been delayed. Originally, the subacute unit was supposed to be live in March. It is still not open. it is still not licensed. So we felt we needed to make a change to maybe have it open on January 1st, so that is reducing the revenue from the subacute unit. We have the inpatient material health unit closing. We originally had it happening within the first three months. We've now assumed that it may stay open for 18 months and so we've had to reduce the amount of savings from having it closed. We did have a birthing center or an alternative birthing center to be put on the campus. So we've delayed that a little bit. And then because the plan is to have the Jerry Sike unit located on the maternal health unit by leaving the maternal health program open there. We delay the JerryScike, so that reduces revenue from the JerryScike unit. So that's a change here. No changes on our estimated cost for infrastructure and epic and see the cost there. And then there are some current projects that St. Rose is trying to get over the finish line and we know there's going to be some more dollars needed to get those across the finish line. And then the next section here is cash flow needed to invest. So we know that there's going to be funds for the subcute and cath lab unit. We know that there needs to be seismant work. That was not done in the original and over study. So we're adding it in here. We've got the cost of the Jerry Psych. We have more IT costs there, a clinic remodel costs, and then the new birthing center, we just have some estimates there. And then down at the bottom, we've got financing needs, and these are blue because these have changed. We do not yet have commitments to forgive the line of credit and the distressed hospital loan. So we've felt it would be best to go ahead and add those in here until we know that we can get some restructure. So what happens is we need 53.2 million dollars in 2025, 17.326, 19.227, 10.9, and 28, and 6.4 in 29. Next slide please. So we've been working on figuring out how we can fund those needs. So I'm just carrying forward at the top there the numbers I just read off. We did hear from St. Rose that they're struggling with cash and that if we were to take over in the beginning of October there would be a cash deficit of 6 million. So I've added that in here. We've gotten quite a bit of community commitments. 6.3 million in 25, 2.5, 2.6, 2.5, 2.7 million, 2.8 million, 2.9 million. the . . . . . . . . . . . . . . . which is not on this slide and we'll talk about that in a minute. Next slide please. So this is just a reconciliation. So basically what I'm doing here is just laying out the changes we made. So our board saw a presentation in mid-August with different numbers. We originally had projected, we would need 17.2 million in 25, 11.9 in 26 and 5.3 in 27. 28, 29 had small deficits, which our board wasn't too concerned with. But when they developed the conditions to close, they took the 25, 26, 27 deficits and said we needed to figure out a way how to cover those. And I'll end with a slide on how we're doing to meet those conditions to close. So I don't know that I need to go through all of these because these really basically just detail out the changes between what my board saw mid August and where we are today. Okay, moving forward. Okay. All right. So when we look at what our transition team is identified as the additional risk that is out there, again, a number of bullets and I'm going to look to draw your attention to a few that I'd like to highlight the second being current and will be tendency to confirm occupancy and revenue impact. We've learned recently that they have lost tenants in their medical office building. And so that was a line of revenue that we initially thought was going to be more substantial than it is based on current occupancies. And so that's something that we are trying to reconcile. Volumes continue downward across the board. I talked about the deliveries having decreased and we're seeing similar decreases in other service areas. The cash flow remains volatile. The St. Rose Hospital Current Projection indicates cash flow is not adequate to cover their shortfalls and then prolonging the transaction and the closure of the transaction. Threatened staffing stability. I think the St. Rose staff have been amazing and they're stalwart and they're hanging in there, but they're human. And they want to make sure that they're going to be able to remain employed gainfully. And so I think that the longer it takes to consummate this deal, we have flight risk of the current staff. And then of course, things like the financials, which is not unusual, but they're behind. And so the most current that we have is July, so we're a few months out on that. And then around May, they restructured the position cover for the maternity service, the delivery service, and the Alameda Health System is really trying to understand the implications of those transitions. Next slide, please. And so, you know, what's our ask? And again, understanding that this is informational and this is not a decision making forum, but the things that we think we'd really like the supervisors to give consideration to assisting with meeting the closing conditions that our board established The foremost one for consideration by the supervisors is the permission to use the negative balance for deficits in the operations at St. Rose. That is something that really we must have. We do not hold our own cash. That's by virtue of the nature of the relationship with the county. So we don't have cash reserves to cover that. And so we anticipate and understand there'll be a need to use the negative balance to cover those deficiencies. And then the IGT funds that are directed to St. Rose and I need to acknowledge that we have worked with Director Chavila and her team and that work is already underway and so I'm very grateful for the collaboration from our partners with Alameda Health. And then the support for the decision to suspend the inpatient L&D service within three months. And I say suspend because I think it's terribly important that we acknowledge we are very supportive of babies being born and hayward, of people being able to have babies in their community. Given the financials that we've just kind of in a high level way gone over, it is not qualitatively or fiscally prudent to continue to sustain the losses that they are now sustaining. And we don't believe that they can have the kind of quality that those patients deserve. So by suspending the program and doing the work necessary to move our centering program and to develop a birthing center as Kim Miranda mentioned, we believe is the right way to make sure that babies can continue to be born in Hayward for the foreseeable future. And by virtue of doing that, that allows us to move forward earlier with the Gerosite program, meeting a critical need in the community, and also helping offset some of the losses that we anticipate. The final bullet on this page is to restructure an increase in that negative balance to support Alameda Health Systems growth. The last time the NNB was adjusted, the Alameda Health System was an $800 million organization. We're now 1.4 billion, which will increase if this deal is consummated. And we believe that it's appropriate to consider an adjustment to the NNB that acknowledges the organization that we have become since the last time the NNB was adjusted. Next slide please. So this is our projection for the current fiscal year for the NNB. The blue line there is AHS, and this was the same graph that's in our finance presentation on record. But once we take on St. Rose, the current projections are that we're gonna have a loss of 42 million this first fiscal year and That's including 11 million IGT that we've been collaborating with the county on But if I the only way I have to help fund that is with our NNB So if we increase the line 42 million we will go over the interim period and we will be right about at the 100 million requirement at the end of the year. So very close at the end of the year but in the November, December timeframe when AHS makes the R maximum draws on the line and then we get our supplemental funding and it comes back down and we have achieved the June 30 in all years. So this year I think we're going to be close assuming everything plays as planned. Next year though when we have another year of losses, we're going to need to do something with the NNB. Next slide. So this is the slide on the progress on closing conditions. So our board, as I mentioned earlier, wanted to make sure that we funded the first three year deficits, which are lower or lower than they are today because of the deteriorating performance of St. Rose. They had said we needed 45.7 million. We have community support of the numbers that are in the 1.3, we rounded up, and now we have letters that have been provided to us for the IGT through the county that is progress, so that's 33.5 million of that deficit covered. We also needed debt relief, and we are waiting to hear how that will go. We do know, I don't know if you want to talk about the governors. I'll let you go ahead and do that. Thank you. We learned yesterday that Governor Newsom chose to veto Assembly Bill 20271, which was the bill that was sponsored by Assembly Member Ortega, and would have allowed for the relief, the early relief of the loan forgiveness as noted there at 17.6 million. And so that was not unanticipated. We knew it was a possibility. We were hopeful. There is still a chance that H.K. could forgive the loan, but they have until the end of the calendar year to do so. And that is problematic for us. One, because we have no assurances that that will happen. And secondarily, we have until October 31st to consummate this transaction, this assumption of St. Rose Hospital. And so their timeline no longer aligns with the timeline that has been established for us to acquire the facility. So that's, that is an unfortunate development. I should also acknowledge that the Attorney General, the Deputy Attorney General, was at St. Rose Week before last and we attended that hearing and I thought it was very favorable. And so we have not heard a final determination from the attorney general, but we are optimistic that given what they heard that day and what we know of their decision process, that they will be supportive of this acquisition. Okay. So you can see from the numbers here, we are, if we have the debt relief, we are getting really close to achieving these closing conditions. However, we did see a pretty big deterioration in St. Rose. So these numbers were based on the August 15th presentation. And as I just, we just walked you through today, the things are significantly worse than what they were. And that would require the draw on the NNB at a much higher level than we had originally shared. I believe that's the end. Yes, that is the end of the presentation on Senator Russell. Would be happy to take any comments and questions. Supervisor Tam. Thank you, Chair Carson. And thank you very much for this update. Clearly we've been tracking this very closely as I know in particular surprise our Mark has has been at every single hearing that she could be. personally as I know in particular supervisor Mark has has been at every single hearing that she could be to try to advocate. Because of the government structure of the Board of Supervisors and the trustees, can you give us a flavor and a summary of the comments and the concerns that you have heard from your Board of Trustees? Yes, of course, I'd be happy to share a sign. Would you would you like to take a moment? Would that be okay? Absolutely. Thank you. Good morning. I'm David sign the chair of our Board of Trustees that didn't really plan to present. I came when I heard the news about the veto this morning. I would say that we are just worried about this situation. So coming into this year's budget for the health system, absent-saint Rose, we started looking at a hundred million dollar deficit. You know, we would have looked down to forty. And if you're sitting there as a board and you're not doing it every day like him, you're thinking, this is kind of wow. Now we're done and then we ended up looking at potentially a five million dollar in the green for the year. But that's based on a lot of savings and things that there's no guarantee that every one of those things is going to materialize. And now we add this and we begin with the outset several months ago a very challenging picture. Then it began to look like this becomes something that could work in the out years. And now we see the situations deteriorating and now we have a delay around whether we're going to get a decision from the state. I gather they haven't told the end of the year to think about the distress hospital alone. And I find myself thinking and our finance chair brought up this idea. Let's go back and look at from a countywide perspective how real is the need for this institution? Or can other institutions absorb these folks because the reality is there's lots of needs around and all kinds of places and we simply can't sink our ship for this and I'd close with the thought that when you teach people to swim you tell them if somebody's in trouble in the water you throw them a life-fuserver but you don't get in the water and our feeling is a board particularly the finance committee is we're worried about getting in the water and pulling the whole ship down. Thank you. I appreciate that. So when I look at St. Rose and I look at the radius, the catch market. You have Washington Hospital that has a cardiac care and are looking at a trauma center. And you have Eden, which is not too far away, which people tell me that's kind of, they prefer to go there for their birthing or Kaiser in San Leandro. And then, of of course you have San Leandro Hospital. The part that I find intriguing about St. Rose and its positioning and what our health needs are is in the area of mental health care needs and I think that is going to be an opportunity. I just have no sense right now if you're looking at like, you know, without the stress hospital overgiveness, almost a $64 million loss and whether taking that on for mental health care in particular and with the Cal Ame reimbursement, I just don't have a feel of how that materialized because you're gonna end up competing just as you talked about with the Burthing Center basically losing $3 million from your financials, that it's just not going to be sustainable. So, the one thing I wanted to kind of understand is the $50 million net negative balance that you're looking to see the county provide. How would that or if it would affect the other facilities within the H.S. systems like the affiliated agreements with Alameda Hospital, your work at St. Leandro Hospital and of course Highland and John George. So I will take the first bite at the apple and certainly Kim welcome your thoughts as well. We believe that we have financial modeling that will allow us to not jeopardize the core and that's certainly a commitment that we've made all along that we must preserve the core and by the core. And that's certainly a commitment that we've made all along, that we must preserve the core. And by the core, I'm referring to our current scope of services, inclusive of Alameda Hospital, San Leandro Hospital, the Womacan Highland Hospital, Fairmont, and all of our wellness centers and clinics. And so that cannot be jeopardized intentionally by virtue of taking on St. Rose. And that's what I think Chersine was alluding to with the analogy around swimming. And so while St. Rose continues to deteriorate from a financial perspective, it does call the question whether we would be able to on our commitment not to jeopardize the core. I stand here today still believing that with the changes that we are envisioning for St. Rose, developing a birthing center. And the birthing center is really predicated on a midwifery driven model. And so I think that that's a model that is, it's been proven to be viable and to have very good outcomes, particularly for people of color. And the presentation earlier, one of the notes was about our beloved Black Birth and Centering Program. And we see an opportunity to move some of that work, two St. Rose, to create a unique model in this community to give a home to our centering program and to make it an attraction. So we do think that not only can we increase the number of deliveries there, but we can do it in a way that is concordant with our mission, and that will be a draw for St. Rose. They have an excellent cardiac catheterization program and STEMI program, which, you know, time is his heart muscle when somebody is having a stroke or a heart attack. And so, you know, needing to maintain that program in that community to make sure that people who suffer a cardiac event can get to care in a timely fashion. And then, of course, post-acute care, Kim talked course, post-acute care, Kim talked about the post-acute care unit that has been delayed, but it's still gonna open. And I think those beds are critical. The augment are post-acute capacity and that of the entire community. And then finally, to your point about mental health. We do have plans to do the Gerro Psych Unit. There are other things that we've been talking about with County Behavioral Health, or excuse me, yes, behavioral health that we believe can be housed at St. Rose that will provide benefit across the entirety of the county. And so, very long answer, but I say all of that to say we believe that there is a viable model that will allow us to augment, supplement St. Rose and not jeopardize the core of the Alameda Health System. I appreciate that. And kudos on the work that you've been doing with the Berthing Center to try to reduce infant mercilities, especially among Black children and women. The agreement that includes the governance and the operation of St. Rose does that give AHS the ability to decide what to do with the buildings because there were a number of empty buildings when I toward the site. Yes, it does. Okay. And so in terms of structure, it stays a private entity. So is there like an affiliated agreement, and a joint powers type authority? Well, the way it's structured currently, AHS would become the sole member of ownership. And so all of the assets of St. Rose would become a part of the Alameda Health System. And so it would essentially remain a private entity of St. Rose would become a part of the Alameda Health System. And so it would essentially remain a private entity within the public system that is the Alameda Health System. Okay, so when you looked at the assets and the liabilities, including the infrastructure there, I guess I didn't see that. I saw mainly cash flows and projections out through 2029. Is that a better outlook? I'm sorry. When you look at the assets and the liabilities overall. So certainly that's factored in and we would acquire all of the buildings and the property that are currently controlled owned by St. Rose. And so there are other things that we've kind of envisioned. We might be able to do on that campus, but none of them have been fleshed out to the point where they would be incorporated in the financials. I mean, he thoughts on that? We did put in for a primary care presence there, so that was one of the items because we want to make sure we can bring folks into St. Rose so we can start building the volumes back. In regard to all the real estate around the hospital, we don't have anything in here to sell any or to do anything like that. Most of those buildings are collateral on the debt that St. Rose has. The other thing I would thank you very much, Kim. The other thing I would add is that we are in active conversations with La Familla, which is in the community and they're actually on the campus already. And so we are talking about how do we enhance the relationship and create synergies with them. We've also had preliminary conversations with the Tiberosovascas Health Center, which is an FQHC, and we believe that there are opportunities again to augment the work of Tiberosovascas and to integrate them more fulsomely on that campus. And so those are all things that are prospective, but we believe will be beneficial to the community and will accrue to the benefit of St. Rose. I appreciate that when I asked about the assets and liabilities I was thinking about the Cal Mortgage loan, which was thinking about the cow mortgage loan, which is the debt. And as you pointed out, it's collateralized based on the buildings and the assets. And I kind of don't want to end up in a situation where there would be a foreclosure type proceeding in the future and what would happen to those assets. So my last question is I know from supervisor will a chance notes that you have been particularly instrumental with San Leando Hospital when she negotiated really hard to acquire it from Sutter and there are obviously differences with St. Rose. So if anyone can do it, you can do it, but I just want to understand, what do you see as the main different challenges? Thank you for that acknowledgement. I would be remiss if I took personal credit. Certainly it was the work of the system. I was at the tip of the spear, perhaps, but certainly many people were integral in that work. And I think there are a lot of similarities with St. Rose to what we did with San Leandro 12 years ago. I think there is a great opportunity to reestablish confidence in the quality of care that is being provided at St. Rose and to reattract the people who live in that community to trust St. Rose to provide care. And that's exactly what we did at Saint Leandro. We literally went out and re-recruited the business. And so the conversations that I mentioned with Lafamilio with Tiberso Vasquez, That's, I think, an example of frankly what we did before and what I believe we can do again. I think we can drive ER volumes. So those are similarities. Some of the differences, I think the reality is, it's very similar. San Leandro was on the precipice of closure. They were a setter facility and Sutter was pretty clear that if H.S. didn't acquire, they were going to shut the facility down of closure. They were a suitor facility and suitor was pretty clear that if H. S. didn't acquire they were going to you know shut the facility down and move that business to Eden. I do not think that St. Rose has the wherewithal to. Go through another RFP process there are really no other suitors that are in the wings that I'm aware of and so I do think that this is kind of a you know it's a pivotal moment for St. Rose. I do believe that H.S. has the wherewithal and the commitment and the capability to make St. Rose viable, but we do need help. Thank you. Thank you. I think St. Rose is a very important institution to serve the people in that catchment area. And I've been pretty consistent about thinking that it's important. Having said that, I mean, I can't remember a time, especially with Lex Ready being there. I can't remember a time that they haven't come before this body, the health committee, and they've had nothing but financial troubles for years and years and years and years. Are they currently paying their vendors? I think currently to pay interest. They're making the payments on the interest. But like they just gave us their cash flow and they don't they're they're going to have to make some adjustments to vendor payments or just something. But they're not behind on their debt payments. There's no interest required currently on the stress hospital loan. I the current board would be dissolved. AHS. Our plan would be to establish a new St. Rose board. Okay. I never thought that the governor was going to go to the detail of the board. So the current board would be dissolved. AHS. Our plan would be to establish a new St. Rose Board? Okay. I never thought that the governor's got a veto the bill from the beginning. I mean, there's too many hospitals in there in that same situation here in the state of California. He wasn't gonna put a new surround his neck on that one. We all knew that. So I appreciate the update. I think that they are auditor and also our county council and the CAO's office need to be really need to have a chance to go through this thoroughly. I don't think I have the capacity to digest it. I think it needs to really have more forensics. Look at it, fiscal forensic. Look at it so that as everybody goes forward, they know the unreasonable doubt what they're really going forward with. We have any speakers on the. I have no speakers on this item. Okay. All right. Thank you very much for the. Thank you. And so regarding the other two reports, really at your pleasure, we can either submit them for the record, but if you would like for us to present, we are prepared to do so. No, we'll just accept them and get copies of them for the record, but if you would like for us to present, we are prepared to do so. No, we'll just accept them and copy them for the record. Very good. Thank you. We appreciate your time. Appreciate it. Do we have any public comment on anything else related to the health committee? I have no speakers for public comment. Okay. With that, I appreciate the presentations. Today we're adjourned. Thank you.