Do you have a moment of silence? Any board member would like to dedicate today's moment of silence? Supervisor McPherson. You know, I don't think we can go without thinking about the people in Tallahassee right now. What happened down there? The young kids and teachers, it just isn't right. We all know that. We don't know why, but we just pray for their healing as best they can. Thank you, Supervisor McPherson. Do a moment of silence, please. Are you just joining in the Pledge of Allegiance? I pledge allegiance to the flag of the United States of America and the Republic for which it stands, one nation under God and indivisible with liberty and justice for all. Good morning, Mr. Palasio. So any changes to today's agenda? Yes, Chair Friend and members of the board. There's one change on the consent agenda. Item number 40, additional materials. There's a revised memo, packet page 341, replaced. Paragraph 14 should read Mental Health Advisory Board, Antonio Rivas. That concludes the revisions and corrections to the agenda. Thank you. Are there any items from board? Are there any items that board members would like to move from the consent to the regular agenda today? Okay, seeing none. We're gonna open it up for public comment. This is opportunity for members of the community to address us on items that are not on today's agenda but within the purview of the Board of Supervisors or if you'd like to make a comment on the consent or regular agendas if you can't stay. I also understand that Supervisor McPherson has a brief public comment he would like to make on an item that is not on today's agenda. When we do that now? Yeah. Actually, there's two comments I'd like to make. One has to do with Central Coast Community Energy. Three weeks ago, the new CEO of Triple CE, as we're called, Rob Shaw and Catherine Steadman and I went down to San Luis Obispo to have an item for the unincorporated area of San Luis Obispo County to join the Triple CE network. We got that on the agenda. And then last week we got a positive vote for the unincorporated area of San Luis Obispo to join Triple CE. That makes 35 governing agencies from Santa Cruz to Santa Barbara County included in this effort. It's a tremendous effort that began here in Santa Cruz County and I can't thank it enough. Our CEO, Carlos Palacios, our legal team that we have including Dana McRae back when we started this, it's been a 10-year effort and we have really the Central Coast region as terrific, our goal of reaching 60% renewables by 2025 and 100% renewables by 2030 is on track. We're way ahead of the state goal of 2045. So I just wanna thank the Triple CE team, the Santa Cruz County for getting us in this position to really address some of the really serious environmental issues that we have here. It's a tremendous organization and it's been a great privilege to work with them. Secondly, we're on a conference call with the California State Association of Counties and they were discussing a very comprehensive plan of statewide to address statewide homelessness. We are the counties, the 58 counties of Santa Cruz are joining the 480 plus cities in the state to address this and do it with availability of funds, funding and cooperative effort and really to get some accountability in this. We need to address this in a statewide manner and we will have a better outline of the package. It's called at home of how we're going to address this in a statewide manner with the governor's office, all the cities and all the counties. It's gonna be a tremendous effort and we're gonna probably have a better idea of the outline of how we are going to go from the start in about two weeks or so. So I just wanted to mention that and I wanted to also mention that Chair Zach Friend has been a very, very strong advocate in the health and human services area of CSAC as well. And we've all pitched in to see how we can address this. It's a statewide problem for sure and we wanna just try to resolve it as quickly as we can. Thank you. Thank you so much. I'd like to open it up for public comment. Good morning and welcome. Welcome back. Good morning and thank you for your services supervisor. Supervisor, so my name is Shalaka Banas. I live in Love, Santa Cruz. I also have the privilege of serving on the Mental Health Advisory Board. I'm joined here today with Serge, the co-chair for the Mental Health Advisory Board and Julie, the executive director of the Walnut Family and Women's Center. We'll be reading a letter which you will find in your packet under written correspondence under letter T and I'd like to give the rest of my time to search. Good morning. The Mental Health Advisory Board recommends that the Board of Supervisors does all in its power to ensure safety and dignity in all shelter services contracted with and or sighted in the county and institute safeguards to address incents which occur. On the night of Wednesday, March 1st, the county contracted to provide a warming shelter to ensure the safety of our people experiencing homelessness. An agreement was made with the Santa Cruz Veterans Memorial Building at 846 Front Street for the building's use. On Thursday, March 2nd, just after 10 a.m., a member of the Mental Health Advisory Board while walking past the building's parking lot, witness Dave Pedley, assistant building manager of the Santa Cruz Veterans Memorial Building, violently and repeatedly attack a client of the shelter. At approximately six foot, three inches tall, Mr. Pedley towered over the female client who was approximately five foot five. He repeatedly shoved her while cursing and telling her she was trespassing. A board member shouted for the attack to stop and was threatened by Mr. Pedley. The client reported that she had been told that she could use the porta potties but had found them locked and was forced to urinate behind them. The attack was captured on building cameras. The board member assisted the client in calling 911. Santa Cruz police arrived, but as often happens, a complaint was not filed. The Mental Health Advisory Board asked the board of supervisors to one, affirm the following for all providers of shelter services in the county. Violence against women shall not be accepted. Violence against those experiencing homelessness shall not be accepted. Violence against those who have mental health or substance use issues shall not be accepted. Two, direct all county departments to not place future permanent shelter programs or temporary emergency or winter shelters at the Santa Cruz Veterans Memorial Building at 846 front street while Dave Pedley is an employee. Three, direct housing for health staff to not renew any contracts or partnerships with the Veterans Village program in Ben Lohman while Dave Pedley is a part of the program and allowed on site and to immediately seek to limit his access to clients as an employee within the partnership. If necessary, permit the housing for health staff to seek new partnerships to manage the program. I can sort of continuing the letter. Julie Messis-Evac. Good morning. I'm Dr. Julie Messis-Evac. I'm a clinical psychologist, but also the executive director at Walnut Avenue Family and Women's Center. So number four, direct housing for health staff to create a grievance system so that any contracted shelter, shelter site, shelter receiving HUD funding or shelter operating in Santa Cruz County has a posted policy and procedures so that any client with the complaint can have it sent to housing for health for review rather than staying with the agency where the complaint issue occurred. Further, direct staff from housing for health to apply for funding to create a new homeless advocate staff position or contract for such a service to speak with clients and service providers and solve issues that arise through this process. If state and federal grant funding is not available, the Board of Supervisors is asked to prioritize funding such a position with staff recommendation of where that funding can come from. We at the Mental Health Advisory Board and Walnut Avenue Family and Women's Center believe as do you that the health and wellness of all members of our community are important. Shelter services for those who are experiencing homelessness of any race, any gender identity, LGBTQIA+, or for those with any mental health issue or substance use issue or who have any other disability or for any vulnerable population whatsoever should not be considered separate but equal. Whether the shelter is set up in response to an emergency weather event, a disaster or some other reason and whether the shelter services are provided by the county itself or another entity, all people deserve safety and dignity. Shelter services should be individualized, well designed, well run and receive proper oversight from the county. We make this recommendation from both a place of compassion as well as a case for better outcomes from our programs and better engagement with some people who choose not to receive services due to these kinds of incidents. Thank you. Thank you. Good morning and welcome. Good morning. My name is Jana Rivas. I am a program manager at Monarch Services. I run a confidential shelter program and I am here in clear affirmation that we too believe that shelter spaces should be safe, trauma informed for all persons of all genders and identifications that a clear, transparent and empowering process for every unhoused person in our community is established and supported by this board in the community so that folks can be heard and that they can understand their process and how they can be served within our community. Thank you. Thank you. Good morning. Welcome back. Good morning, honorable board members. My name is Emily Chung. I'm the public health director for our public health division here in County of Santa Cruz Health Services Agency. I wanna thank the chair for signing a proclamation for next week, which is National Public Health Week. I'd like to take the opportunity to read this proclamation and honor our public health staff as well as the whole community that serves in public health. Proclaiming our April 3rd through 9th, 2023 as National Public Health Week. Whereas the week of April 3rd through 9th, 2023 as National Public Health Week in recognition to the contributions of public health in improving health and achieving health equity, honoring the theme of centering and celebrating cultures and health. And whereas in the last year, the County Santa Cruz Health Services Agency Public Health Division continued leading the response to the local COVID-19 pandemic, responding to the MPOC's outbreak, activated medical health resources to winter storm and flooding emergency shelters. And whereas the Santa Cruz County Health Services Agency Public Health Division has committed workforce design and implement evidence and data-driven programs, ranging from health education, infectious disease mitigation and surveillance, public health nursing, and harm reduction through community collaboration. And whereas community partners are an extension of public health in preventing, preparing for mitigating and recovering from the impact of a full range of health threats, including disease outbreaks and climate change impacts. And whereas studies show that small strategic investments in disease prevention can result in significant savings in healthcare costs and an increase in local public health spending contributes to decreases in infant deaths, deaths due to diabetes and deaths related to cardiovascular disease. And whereas the County of Santa Cruz Public Health Division is dedicated to fostering cultural connections supporting our community's health and quality of life and recognize that race, place, culture and social determinants of health impact being able to make systems changes to the community health and wellbeing. So thank you for this proclamation. And one last thing I do want to know is that Thursday is also National Doctors' Day and next behind me is Dr. Newell, our County doctor. So we want to recognize all of our doctors in our community this week as well. Thank you. Morning, Dr. Newell, welcome back. Good morning, Dr. Gail Newell, County Health Officer here to remind you that next week, as you've just heard is National Public Health Week. And we have so much to celebrate. I'm very pleased to be with you here in person today, which hasn't happened enough during the past three weeks, three years. Later this week, our local public health emergency will come to an end and our local state of emergency 30 days after that. We have a lot to celebrate. Although COVID-19 will be with us for the foreseeable future, the pandemic emergency has passed and the County of Santa Cruz fared far better than most. Thank you for your support, Supervisors, CAO Palacios, County Council, Sheriff Hart and his team and the countless others who supported the work of public health during these past three difficult years. It took every community member to practice public health during this pandemic. We thank them all. And while we mourn the precious lives lost, our County's mortality rate is one of the lowest in the state, even in the Bay Area and less than half of the national average. But there's so much healing to do in the wake of the pandemic. Our community deserves enormous credit for coming together and doing the right thing to protect its most vulnerable members. So again, thank you to all. Community is where we are. It's our sense of belonging. It's our connections with others with whom we live, work and play. Over the past three years, these connections have been greatly impacted. Physically distancing from one another and limiting communal gatherings has led to social isolation, increasing rates of depression, impaired immunity and premature mortality.  We have much to do. I urge you to use a health and all policies approach as you do your work, improve housing, education, food, transportation and the environment to support equity, resilience and health at the individual and community levels. Fund programs to prevent unhealthy living conditions and of course support the public health workforce and their efforts. Thank you. Thank you, Dr. Noel. Good morning. Welcome. Good morning supervisors. Thank you for your time. My name is Chris Cottingham and I'm the executive director of the Santa Cruz County Veterans Memorial Building Board of Trustees. The Santa Cruz County Veterans Memorial Building Board of Trustees is the nonprofit that operates the Veterans Memorial Building in downtown Santa Cruz, the Veterans Village in Ben Loman as well as several other programs supporting veterans and community and many of those experiencing homelessness. We have a strong reputation in the community for providing unbiased support including shelter, food, medical services to all in our community that have fallen on hard times. We do not promote or support violence against anyone including women, those that are experiencing homelessness and or those who suffer from mental health or substance issues. Seems like Mr. Cagno's account of the event is very different from our understanding of what happened immediately after the events on the 2nd of March. Our staff made contact with the Santa Cruz County Police Department. They responded and interviewed our staff, reviewed the security footage as well as interviewed other parties and determined there was no followup needed. It had seemed like the unfortunate situation was resolved without further incident and at the time we did not press charges against Mr. Cagno for violating the no trespass order against him. We were very surprised to learn that this letter was being presented in the public forum for discussion without anyone contacting us to verify or fully understand the incident before presenting it publicly. We do take these allegations seriously and we will review our policies to ensure we remain prepared and committed to serve our entire community to the best of our ability. We will do so by ensuring our staff have the most up to date support and de-escalation training and remain committed to serving our most vulnerable with dignity and the respect they deserve. We also continue to work with the County of Santa Cruz and the shelter operators to ensure there are clear options for participants to access facilities and services. We asked that the name of the employee be redacted from the public record. This is a personnel matter still under investigation and we do not believe this is the right venue for discussion or deformation. Thank you. Thank you. Good morning and welcome. Good morning, my name is Ray Krulicki. I'm a civil engineer, I'm an architect and I'm a contractor and I'm speaking for 70 people that live on College Drive. This is for Supervisor Philippe. You can see the 70 names. We're tired of being flooded out every five years and the problem is very simple. Could be simply solved. In San Jose, the mayor was bragging after the first rain, she dug out all the rivers and creeks and everything flowed fine. I hear rumbling and Monterey to Palo River, the farmers wanna dig the river out, they wanna take the trees down like they did in 95. On College Drive, there is a five foot culvert going under the road and the culvert is filled with water in September and August. It doesn't rain in September and August and I'm gonna tell you, water goes downhill. It doesn't go uphill and that's the problem. You have to dig the river down four feet at the bridge that was built in 1936. The last time the supervisors did anything in Santa Cruz County along the river that's around College Drive. It needs to be dug deeper. It's a simple solution. You don't spend a million dollars putting a pump in a lake to pump the water out. The river flows and when the river is high, the water pumps into the lakes because the water finds its own level. What you did is fine. But I would rather you spend a couple of hundred thousand dollars digging the river deeper than running pumps for five days at one million dollars. Does that make a lot of sense to you? I'm asking you, you can comment nothing. Does that mean you're not gonna do anything? Because 70 people are here to complain and a woman on the street, College Street wants to do a class action suit against the county. I don't want to see that because I guess you pay. Thank you, sir. Thank you. Gary McDonald, supervisors. Some of you haven't been here all that long. But we've continued to have like the gentleman there was talking about the board refused and it got rid of the citizens appeals board for planning. And they appointed themselves as such. And just like the man talks about physical stuff about water running downhill, the fulcrum of a eucalyptus tree is at its base when it's in water and on refuse and one falling over every six weeks. And I can't get a recall for my supervisor sitting right there that ran synonomics that's supposed to get everybody engaged. Well, I had to wait for a lady to get out of her parking lot to park there. You can't go to the quarter or 10 these meetings. There were only five copies of the agenda out there. This is deliberate. We've had people concede on TV. There's all kinds of people back here designated speakers working for the county to burn up time. You've adopted only two minutes to allow the people to talk and you blame that on Neil Coonerty. You're the chairman now, Zach Fran. You work for John Kerry, who was a registered lobbyist for the Red Chinese. Bruce McPherson's been working on this thing with Palacios as CEO. He go over the headquarters, Palacios isn't here. He receives $3,065,000 a year in pay and he's not even here. And Bruce McPherson, you're still receiving benefits by the Red Chinese. You got tens of thousand dollars from communist Chinese by Catrice Lung. And you know it and all of you support a two plaques on the courthouse steps dedicated to Red Chinese communists by that help kill your parents and your cousins and people in your family. This place is outrageous. And the reason why we have high gas and the cheapest inefficient energy is because of Bruce McPherson and Palacios following the UN agenda, ICLEI 21.  Thank you, Mr. Arnold, good morning, welcome back. Good morning, board of supervisors and specifically supervisor Cummings. I live in your district where I am the mother of one of the three family court kidnapped Santa Cruz children. I've been coming here weekly. I am asking you for help. I was deeply disturbed to learn of Senate bill 43, which is conservatorship reform and assembly bills 665. Both of these bills would seek to expand medical kidnapping of children and our most vulnerable population. I would draw your attention to my letter written to the Santa Cruz city council for today's agenda item 14, which explains how easily medical doctors can be bought off to write false reports. I'm deeply concerned that Senate bill 43 would seek a hearsay exemption for information contained in a medical record presented by an expert witness. This is absolutely not allowable. We cannot do that. That is our due process safeguards and I'm horrified that there would be any bill to do this. I am horrified to hear that according to the gateway pundit, there is a state sanctioned kidnapping California Democrat that pushes a bill that would allow therapists to snatch children from parents without trial. Supervisor Cummings, I'm asking you to support me in putting these bills down. They must not pass. And I'm asking for your help to get my daughter rescued from medical kidnap and the other two children who've been medically kidnapped. I would like to hear from you either via an email to make an appointment with you and get these children rescued and not kidnap any more children by doctors who would be paid to tell lies. Thank you. Good morning and welcome back. Thank you. Becky Steinberger, resident of rural laptops. I first want to say, I'd really like to see this barrier leave. Yours are all gone. There's are all gone. Our barrier is still here. It doesn't look good. Please take it down. I want to support what the woman before me said. I have grave reservations about the large facility the county has now purchased across from this sheriff's department at 5,300 SoCal Avenue where it will be a residential kids center for mental health. There's something that bothers me about that a lot and this woman's testimony enforces that. I want to bring your attention to a letter that I see in your correspondence that I really hope you read and that you also respond to. It is a letter from Mr. Dave Martone from the Paro Valley Fire Protection District asking you to reconsider your allocation of Prop 172 public safety money. You know what this is. It was passed in 1992 to fund public safety, fire and sheriff. This county gives $0, $0 to the fire protection districts out of the 20 million that we got last year from this permanent house state-wide sales tax. You know that you can reallocate that. You know that you can do that and it is time to look at that again because of the changing wildfire conditions and the needs of our county to prepare and to suppress those types of fire. Please read and respond to Mr. Dave Martone's letter. I'm very concerned about item number 49 sharing information about vaccine hesitancy with the National Association of County and City Health Officials. I don't think that is a good idea and I want to protest the county spending in item number 63 million dollars to help the Aptos Village Project developer Swenson for their project and traffic things on Soquel Drive. Thank you. Morning, welcome back. Hey, good morning. What is it? It's May, March 28th, 2023. This is the Santa Cruz County Board of Supervisors meeting. You know, it's really quite amazing the full house we have here. You know, I'm really appreciative that Sheriff Jim Hart is here and that Gail Muell is here. You know, I kind of came prepared to talk about a lot of things but maybe I'll just focus on a conversation that came up on Sunday and I practice boundaries. Someone clearly stated to a group that the current sheriff in this county, Jim Hart is not a constitutional sheriff. It inspired me to practice boundaries but write something that, you know, I'm just glad that I wrote. So when you stand outside this building in front of the actual courthouse, you have two distinctly different US flags, distinctly different than these two flags that have a gold fringe upon them which those are under maritime law. Those are pirate flags. So I didn't embarrass the person that's been teaching common law in this county for a while but anyone can go into the basement and they can find a plethora of information, specifically information about the first US constitution that was published in 1787 with the first 10 amendments and then the second US constitution that was published in 1789 and the third was published in 1790. Further, if you go through to the February 23rd, 1871 Organics Act which created the tri complex where the US corporation in Washington DC is just the military branch of the Vatican and the Bank of London. And then you go to the creation of the tax identification number where unfortunately most citizens don't realize that under the law they are corporate citizen slaves. I wish I had some more support. I'm glad these people are here. I'd like to talk to both Gail and Sheriff Jim Hart. Thank you. Thank you. Good morning, welcome back. Good morning, how you doing? Luc Rosito again,<PHONE_NUMBER>. I have my client here that I've been trying to build her house here. It's going on three years now. Can't blame you all for the weather that we've had this year of course but if the planning department was more adept, this house should have been built already. I do have permanent information for you guys from 45 years of experience of the mistakes and stuff that your planning departments made here. I would like to be heard. I'm in Mr. Koenig's district. She's in your district, Mr. McPherson. And I like having a young person, Mr. Cummins on the board. I think my generation and the previous generation screwed things up enough. And these codes that you're working off of maybe back to the 80s for which Gary Patton stated at a meeting here, we can pass policy like this all day long because it's too expensive to test it in court. I was at that meeting, that's a quote, okay? I would suggest the younger generation here which I'm happy to see and experienced generation McPherson, you got to look at your planning codes here and you got to simplify. We've got to get people in their homes. In the 80s and 90s, you had a growth factor of allowed 3%. We were growing at 12%. So the first spec house I built and sold for $136,000 is 1.8 million today. So we're all stealing from our grandchildren. We really have to do something about this, okay? I appreciate what you go through, you guys. You're on the hot seat all the time. I don't wanna run. I've been asked to run for supervisor in this district for 12 times in the last two weeks. I don't wanna do it. I did six years on the school board. I had more fun getting shot at in the Army. So I don't wanna do this.  You give the direction. You don't take direction. You give the direction. Thank you very much. Have a nice day. Thank you. Morning, welcome. Cindy McDonald, school teacher in East San Jose, sorry. I wanna go home. I wanna go home. From the very first day that they cleared the debris, this county has lost my paperwork several times over and over. The second debris removal, which was not necessary because my paperwork was lost. It has now cost me another extra $100,000 for that raping of my land. Please help us. We're running out of time. We do not have a hailing money after August 20th. You're gonna have 900 people homeless because we can't afford the mortgage and rent. Please help us. I wanna go home. Thank you. Is there anybody else in chambers I'd like to address us? Madam Clerk, is there anybody online for public comment? Yes, Chair. We do have speakers online. Thank you. Carol, your microphone is now available. Good morning. Wow, my heart really goes out to that last speaker. And all the people who are looking to rebuild their homes, it's really unfortunate that they weren't able to get their homes built in the last 2020 or 2021 before all these rains have started in 22 and 23. It's really unfortunate. But I'm actually here to speak about agenda item 49 on the consent agenda. I'm gonna ask that you all delete that item or at least amend it. It's about the vaccine hesitancy project. A hallmark of an oppressive government is propaganda. A hallmark of a free society is the empowerment of the people and the free flow of information. So if you guys don't delete it, then I would like to suggest that you amend it and that you use that money to purchase Dr. Thomas Cowan's book. It has a wonderful book. It's called The Truth About Contagion. Exploring theories of how disease spreads. And you can place copies of the book. I would give the first copy to the public health department and the rest of the copies you could give to the county office of education, to all the schools, to all the libraries so that we could empower the people to know the truth. It's really unfortunate when the propaganda has continued for three years. It's astounding. And all we have to do is read a book to find out the truth. So I would encourage you all to get a copy of this book and again, just share it with the community. You all can get a copy for yourself, educate yourselves so that you really do understand about the truth about contagion and you would read about how disease actually spreads. That way, we would be a much healthier, much empowered community, much stronger, able to rebuild our lives and our homes. Thank you. Thank you. Colin, user two, your microphone's now available. Marilyn Garrett, thank you for Carol Peorn's recommendation. I have this book right in front of me that she referred to. And I'd like to recommend a few more sources of that. And the evidence, the contagion myth, why viruses, including coronavirus and quotes, are not the cause of disease. He refers to people being exposed to poison, contamination, radiation, starvation, poor nutrition, as true causes of disease. And I want to second Carol Peorn's recommendation that you delete item 49 and put that money into putting out truthful information on facts. Another book is the real Anthony Fauci, Bill Gates, Big Thief, who is the author of the book, Fauci, Bill Gates, Big Pharma and the Global War on Democracy and Public Health by Robert F. Kennedy, Jr. Another source is Weston A. Price Foundation, westonaprice.org. I have in front of me eight and a half, 11 sheet titled COVID Shots for Adults and Children, what we know now. And there's a whole list of adverse reactions that are to be expected and documented. Why are you promoting Big Pharma's poisoning of people with these injections? One point here, in every clinical trial of COVID Shots, nearly all participants reported adverse reaction, including high fever, chills, muscle pain, and headaches. Thank you, Ms. Garrett. Thank you. Is there anybody else online, Madam Clerk? Yes. Barry Perlman, your microphone's now available. Thank you and good morning. Hi, my name's Barry Perlman. I live in the fourth district. We live outside Watsonville at one of the lakes in Interlaken District. We live just above Drew Lake. I'm here this morning to thank county government for the superb response that I witnessed in the very first person. On March 10th, our property severely flooded. Our foundation of our home, which is 120 feet above Drew Lake, was completely unflooded. And we have damage to the frame of our house and the foundation. And it was pretty radical situation. Thank you, guys. I saw action. I saw people responding, coming to my home, standing on my deck, which became a dock and assessing the situation. I watched the various departments, public works. Matt Machado's people did a great job. Alec Sandoval, direct road superintendent, Marvelous. Felipe's team, Ramon Gomez, Marvelous. These people were hands on day after day after day, spending their time in the rain, overseeing the work. First of all, it was just terrific. You saved many of us. Thank you very much. And with that, I bid you a great day. Thank you. Call and user 1733, your microphone's now available. Call and user 1733. Hello, my name is Dr. Madeleine Altman. I'm calling regarding number 49, continuing on what Carol and Marilyn were saying, regarding doing a deletion of this, or perhaps an amendment at the same time, referring you to people who can give you information. To me, looking at this looks like it is from public health, which is who's been on here earlier today. Public health is wonderful for water and sanitation. They are Department of Defense. They are, what they should be doing is helping people, not injecting them with viruses or some unknown, untested, unqualified, does not stop transmission, completely propagandized situation. They need to get out of this. Money should not be going to that. There are many things in this county that money can go to. And again, these things are causing the mental health, the disease, the diabetes. These are what they consider vaccine or whatever you want to call them, injections. Look at the CDC, not my word. They cause asthma, they cause diabetes. Please stop more of this. I don't know what vaccine hesitancy is. Somebody said something about surveillance. We used to call it as doctors, tippa, privacy. You don't give information, and specifically medical. If you see the word vaccine, think of it as drug. If you look at drug hesitancy, it is good. Thank you. Thank you. This is a last call for online speakers. Chair, we have one speaker left at this time. Mila, your microphone is now available. Yes, hello, do you hear me? Yes, we can hear you, thank you. Yes, oh, I have a good words to say and maybe it will be finally heard by that board that silence is a violence. And I cannot get any response from this board. My email on March 13 was published and it was an email ending on March 13 and was beginning on November last year. I requested for urgent help and it's just outrageous because it's already 10 years like we got humiliated and destroyed by the care of a health division that completely not doing their job for society. Instead, they trying to destroy society is very hard. I've heard here community, you know, bridges that they need money and they got part of money for their service and they really provide help to people. Why you do not fund such salaries for mental health employees? It's too many of them who does not have certification from California board and who's only doing a bad job and destroying people. I live in health, my daughter live in health, your brain was destroyed, mind, soul, everything was destroyed into a nervous system destroying right now every single day. We have no appropriate actions, we have no appropriate services and this is just outrageous. Where is the district attorney? I would like to see district attorney here. Is he alive or he is not alive? Why it is impossible to get any appointment at the sheriff department to talk about that issue? They just put in this and district attorney is the same thing. Thank you. Thank you, chair. We have one last speaker who's raised their hand. Call an user 1192, your microphone's now available. Hi, hi, thank you. This is Gail Necunum and I'd like to comment on an article from Reuters news agency via Yahoo Finance talking about insurance claims that have been paid out before the vaccine rollout in one agency called Aegon that was only 31 million but after three quarters of aggressive vaccinations through 2021 the death benefit payouts hit 111 million an increase of 258% and here's part of the article. Dutch insurer Aegon which does two thirds of its business in the United States said its claims in the Americas in the third quarter were 111 million up from 31 million a year earlier. US insurers met life and prudential financial also said life insurance claims rose, rose South Africa's old mutual, not really making sense in this sentence but more of its pandemic provisions to pay claims and reinsure or Munich Ray raised its 2021 estimate of COVID life and health claims is 600 million euros from 400 million. This is a historical increase in death. From the United, another website United States Holocaust Memorial Museum they talk about the fact that certain basic principles must be observed in order to satisfy moral, ethical and legal concepts. I interject here that no animal trials have been done on this vaccine that we know of and the vaccine manufacturers have not revealed the ingredients so informed consent is not possible. The first number of the 10 rules or suggestions of- Thank you. Is there anybody else? Madam Clerk. We have no further speakers chair. All right, thank you. I'll close public comment and bring it back to the board for consent. Supervisor Hernandez, is there any item you'd like to discuss on consent? Thank you. Supervisor Cummings. I did have a couple of comments. Item number 34, which were the reappointments for the district three office, we received a letter yesterday from the person who was going to be reappointed for the mobile and manufacturer home commission and they submitted a letter of thanks but they were not wanting to continue on in that position so that individual should be removed for consideration for that item. Okay. In addition to that, I just wanted to thank the staff item number 47, which is a mental health liaison grant for expanding the mental health liaisons that are with the sheriff's department. Just want to thank the sheriff's department for applying for that. We know that we've been hearing a lot from members of the community who want to see us expand the number of social workers who are going out in the community engaging with people who may be suffering from mental health issues. And so I think that will continue to add in our efforts on that front. In addition to that, I wanted to thank staff with item number 48, which is a housing and homelessness instead of payment program for a street medicine pilot grant. And again, a lot of people wanted to see more teams going out and engaging with people experiencing homelessness and this is an opportunity for us to expand medical services that are able to go out and engage with people who are where they're at rather than having to have people come into our facilities. And so increasing our ability to contact people who may need medical treatment who are homeless, but also being able to help connect them with services and hopefully get them housed. I did have a question for staff and maybe this is one for Matt McChaddle. It's on two items. Item number 62, which is recovery center modular project contract approval and item number 65, which is the crosswalk upgrade. And the only question I had is that it seemed like the initial base estimates for work were half of what the final bids were. And so I'm just wondering if maybe we could speak to that. So the first, for item number 62, the base estimate was 545,000, but the final bid came in at 1.1 million. And then with 65, the base estimate was about 159,000 and then the lowest bid was 374, so I'm just wondering if you can maybe just clarify why we're seeing that big a difference in the base estimate versus what the bids are coming in at. Sure, thank you. Good morning Supervisors, Matt McChaddle, Deputy CAO and Director of CDI. I'll take 65 first and then Damon Adlow will address 62. So on, wait, 60, yeah, 65. And so this is a very unique contract, a very specialized equipment. We don't normally bid these out as standalone small projects. And so our experience with estimating this unique equipment, specialized equipment is less than our normal experience with bidding road projects and such, that also explains why we only had one bid. And so that specialized equipment, it's unique. It is a critical project I'll share and we also worked with Caltrans. They recognize the criticality of it as well and funded the entire project, it's 100% grand funded. We do think that the bid is a good bid. We also think that the price is fair, it's just our estimate was off because of our experience in this very unique equipment area. So we're making a solid recommendation to the board today. And so hopefully that explains a specialized equipment and construction costs are up a bit too, but I think specialized equipment is driving the cost, but it is 100% grand funded, which means that Caltrans recognizes the value in it as well. For item 62, I'll turn it to Damon to address that one. Hello, board supervisors. I'm Damon Adelaide, project manager with a CDI. So yeah, with item 62, we initially had an engineer's estimate, which honestly was just a lot lower. You know, then we had thought it was about a three, basically about a three year old estimate. We thought we had applied appropriate escalation to it. We hadn't. Once we received the bids, we actually took some time to test the numbers, essentially with unit pricing that we had. We were pretty close. The other issue was that we only had one bidder. As explained to us kind of during the storms, it was just difficult for folks to get there. But again, once we tested those numbers, it felt like it was within a reasonable range. And that by going out to bid with the time involved that we wouldn't necessarily result in lower prices. And that's why we recommend moving forward with it. Okay. Thank you. Thank you. Those are all my questions and comments. Thank you, Supervisor Cummings. Supervisor McPherson. Two items, under number 20, the Brands of Forty and Scotts Valley Fire District consolidation. I'm glad to see this work to consolidate the two fire districts. I think whenever it makes sense to consolidate smaller agencies to better serve our residents, it's a good financial sense. I know that the Scotts Valley Fire District will do the best job it can to serving its new customers in the former Brands of Forty service area. And item 35, the fire suppression bill. I want to thank the little supervisor, Justin Cummings for coming to me to co-sponsor this item. As we all know, greater clarity about FEMA's role in supporting local governments in covering costs of hazard mitigation, as well as providing post disaster responses, most welcome. Federal legislation like this is to plug some of those gaps is good. And I hope there's more forthcoming about FEMA's responsibility to provide their support in a timely and predictable way. This hasn't been the case for the past several years and is substantially impacting our county budget due to lack of reimbursement for the county related incidents to seize the U fire and the COVID response. We're in the neighborhood of $70 million that we think should be coming to us, but we're just going to continue to press for that. And I appreciate you bringing this to us. Thank you. Thank you, Surveyor Koenig. Thank you, Chair. I also want to comment on item 20, the merger between Brands of Forty Fire Protection District and Scotts Valley Fire Protection District. I just want to congratulate these two agencies. I know for Brands of Forty Fire, it's not easy to give up its identity in this way, but the agency did some hard work and ultimately put their residents of best interest in efficient fire service above any personal pride. This merger is a wonderful example of public service. It's an example of putting service above self. On item 32, I want to accept the nomination of Julie Peterson for appointment to the Santa Cruz Monterey Merced Salmonita Mariposa Managed Care Medical Care Commission. I want to thank Ms. Pearson for volunteering for this position as hospital representative on the Health Alliance Commission. She's extremely qualified as the Chief Financial Officer at Watsonville Hospital today. And before that was CFO at Dominican and Sutter for a combined 17 years and has 25 years of experience in the healthcare field. Ultimately a strong working relationship between Watsonville Hospital and the Alliance is crucial for their long-term success. So I think this will be a great appointment. And then finally on item 67, the Monterey Bay Air Resources District Grant for 17th Avenue Adaptive Signal Project. I want to thank and congratulate public work staff on the successful grant award of $200,000. And hope we can find the remaining funds needed to implement this important project as soon as possible. Thank you, Chief Advisor Koenig. I'll briefly comment on a few items on items 58 and 59. Appreciation to Mr. Wiesner for continuing to stick with the 2017 storm damage repairs. These are major damages within my district that have now been completed. Item 64, Mr. Adlow, thanks for your continued work on the Aptos Library. I think the solar is gonna be an amazing addition to it and it's exciting to see that it'll provide enough power to cover it for 20 years. It is an absolutely stunning project. Every time I go by it, it's just a beautiful monument for future generations. So I appreciate your work on that. Okay, so we'll bring it back to the board recognizing that we need to amend item 34, striking Mr. Allenbaugh from one of the considerations. What if we could have a motion, please? I'll move consent. Second. So we have a motion from Supervisor Cummings and a second from Supervisor Hernandez with the one change on item 34. If we could have a roll call, please. Certainly. Supervisor Koenig. Aye. Cummings. Aye. Hernandez. Aye. McPherson. Aye. And that passes unanimously. And so we'll move on to the first item of the regular agenda, which is to consider item seven, which is to consider approval of a new access to medical care agreement with Kaiser Foundation Health Plan Incorporated and Kaiser Foundation Hospitals Incorporated and Take Related Actions. There's outline to the memo of the Director of Health Services with the agenda board memo as well as the access to medical care agreement with Kaiser Foundation Health Plan and Kaiser Foundation Hospitals. With us today we'll have Monica Morales, the Director of our Health Services Agency and Tiffany Cantrell-Warren the Director of our Behavioral Health Division. Director Morales, good morning. Good morning. Thank you for having us here this morning. Just a quick reminder on December of 2019. Oh, thank you, Carlos. Should I project? It is on. Can you hear me now? Is that a little better? Okay, great. So on December 2019, the board directed HSA to negotiate a new agreement with Kaiser. At that point, Kaiser had entered the Santa Cruz market the year prior to this directive. After about a year and a half negotiating with Kaiser, we bring forward to the board a consideration to approve the access to medical care agreement with Kaiser. Just want to take us back a little bit and remind the board that we currently have access to medical care agreements with three health systems in our county. Dignity Health, also known as Dominican, with Sutter in Watsonville Community Hospital. The access to care agreements are really then tent and the goal is to ensure that the largest health systems in our county provide inpatient emergency and other healthcare services to our poor and low income and indigent patients. It's really our attempt to ensure that all of us are caring for our populations most in need. Kaiser can fulfill its agreements very similar to the categories we have with existing plans right now. So these include contributions to charity care, uncompensated care for non-Kaiser patients, grants for health needs, as well as recruitment of physicians that will serve non-Kaiser patients. Tiffany will jump into the details with you this morning to showcase more what the agreement entails. I want to extend our gratitude to Valerie Lomax, Evelyn Tran, and Irene Chavez from Kaiser who really worked with us for the past two years to ensure that this agreement give forward to the board for consideration. I'm also in deep appreciation to our team members, Tiffany, who really spent a lot of time thinking through the concept of this agreement to ensure that it was fair and it matched and it was balanced compared to the current agreements that we have. And Mary Chavez for her ongoing research to ensure that we had and we're mirroring also the commitments that we currently have. So with that, I want to transition now to Tiffany who will give you guys more detail and we'll be here to answer your questions. Thank you. So a little bit of history about the state law. It requires that nonprofit hospitals assume an obligation to provide community benefits in exchange for their tax exempt status. California also requires hospitals to submit to the Department of Health Care access and information, the hospital community benefit plans and annual reports and also to assign an economic value to the charity care, uncompensated costs of care and other community benefits that those hospitals provide. The state does not, however, require a minimum contribution amount of community benefit from each hospital. So in Santa Cruz County, we leveraged the access to medical care agreement to achieve a minimum annual community benefit contribution amount from nonprofit hospitals and health systems that are operating in our county. The access to medical care agreements enshrined shared commitments to Santa Cruz County residents. Santa Cruz County does not have a county hospital. And in a smaller population county, residents are best served through partnerships that allow access to medical care for specialty services for people regardless of who their insurance payer is. It's a very delicate balance in a small county such as this. The access to medical care agreements made by Santa Cruz County hospital providers ensure that specialty care, inpatient care and emergency department services are available to our MediCal beneficiaries and other county indigent patients. And this is really important because 33% of Santa Cruz County residents have MediCal. So here is a summary of the community benefits required and provided by each of the health systems where the county has a current access to medical care agreement. This is for the most recent reporting year 2020. It was brought to this board through the consent agenda on February 28th of this year. And so you'll see that for Dominican, the required contribution of care amount is $7 million. And ultimately in 2020, Dominican contributed 11.5 million. For Sutter, the required care amount is 2 million. And they came in just a little shy of that. And for Watsonville Community Hospital, the required care amount is 1.9 million for 2020. And ultimately they provided $2.3 million in community benefit. So the County Health Services Agency has negotiated the agreement before you today with two parties that we will collectively refer to as Kaiser. That is both the Kaiser Foundation Health Plan, Inc. Which is the Health Insurance Plan and Kaiser Foundation Hospitals, Inc. Which is the hospitals and the medical offices. This is a 10-year agreement that begins last year in 2022. The parties can agree to revisit or renegotiate certain provisions upon mutual agreement in 2025. The annual required commitment of community benefit for this agreement will be calculated as 2% of Kaiser Health Plans, annual commercial dues received from Santa Cruz County residents. Because Kaiser does not have a large hospital facility footprint in this County and because Kaiser operates as not only a direct medical service provider, but also as a health insurance plan. This agreement with Kaiser pagues a minimum required community benefit to a percent of the commercial health plans revenue, which Kaiser is intrinsically motivated to grow. The existing access to medical care agreements that were made with hospitals in the 70s and in the 90s and those hospitals later joined with large health systems. Those agreements pay the minimum required community benefit to a percent of the operating expenses of their large hospital facilities. So the result here is that in the reporting year of 2022, Kaiser's minimum required community benefit will be approximately $4.5 million. We can compare that to, for example, Sutter's minimum required community benefit for the last reporting year, which I showed you on the previous slide, was $2 million. So without having a large facility footprint, Kaiser's minimum community benefit requirement will still be double what Sutter's is in the existing access to medical care agreements. So this arrangement ensures that as Kaiser's business in Santa Cruz County grows, so does its community benefit to our County. This arrangement also maximizes the benefit to the community of Kaiser being not only a direct medical service provider, but also a health plan. And this is different than the other health systems operating in our County, whose historic agreements are tied to their hospital facilities operating expenses. So now I'll describe the multiple ways that Kaiser can fulfill the minimum community benefit contribution to our County. Kaiser can fulfill its annual community benefit contribution through provision of charity care or uncompensated costs of care to non-Kaiser patients who are residents of our County. The non-Kaiser patients includes individuals who are uninsured or who have non-Kaiser Medi-Cal, non-Kaiser Medicare government insurances. This care must be provided in Santa Cruz County Kaiser facilities. It can also be provided by Kaiser physicians who are operating in our County, including those operating at Watsonville Community Hospital. It can be provided via telemedicine to residents within Santa Cruz County. And it can be provided by Kaiser physicians who are practicing outside of the County, only for procedures or services that are not available within Santa Cruz County and where the physician believes that the best care can be provided elsewhere. However, at least 50% of charity care that's counted towards the annual commitment must be provided within the geographic boundaries of Santa Cruz County. Kaiser cannot count the value of care provided to its own members as part of the annual required community benefit. So what this agreement does that the existing access to medical care agreements do not, is it caps the financial value of charity care and uncompensated costs of care to the most recently approved CMS Medicare fee for service rates for Santa Cruz County plus 20%, which we believe more accurately reflects the true costs of care than what hospitals currently report to the state HCI in their community benefit reports and what the hospitals report to the County in their access to medical care reports. So Kaiser can also fulfill its annual community benefit contribution through grants made to nonprofits that support any of the top five health needs that are identified in either Kaiser's internal community health needs assessment for this area or the joint community health needs assessment that is developed in partnership with the public health department and the other health systems. So here we've focused the grants and what can be counted towards community benefit on those five highest needs that are identified by our community. Kaiser can also fulfill its annual community benefit contribution through recruitment of physicians to the Santa Cruz County area who must be based in Santa Cruz County and must provide care to MediCal and MediCruz, which is the County indigent patients. Here though, we've capped the physician recruitment expenses that can be counted in this agreement at $150,000 per physician. Keep in mind that many provider medical groups may spend upwards of $400,000 recruiting specialty care physicians and that the current access to medical care agreements do not cap the per physician recruitment expenses that can count towards the minimum annual community benefit contribution. Kaiser also made many noteworthy contributions to the Pajaro Valley Healthcare District and Project in the past year, which were crucial to pulling the Watsonville Community Hospital out of bankruptcy and returning it to community ownership. Kaiser can count towards its annual community benefit contribution, those in kind services, which include consulting, accounting and administrative services or the grants that were made to the health district to acquire the hospital for public ownership. There is the initial grant of $3 million that Kaiser made and then also a $4.5 million pledge that Kaiser made and will be paid in three installments starting this year. In kind services that Kaiser counts towards the minimum annual community benefit contribution must have a monetary value assigned to it that is mutually agreed upon by Kaiser and the Watsonville Community Hospital leadership. This agreement requires annual reporting via the access to care worksheet, which will provide the amount of the annual commitment for the reporting year and the amounts expended in contributions towards that annual commitment. The report submission will also include an external auditor's report, an annual report of the grants and the physician recruiting expenses that Kaiser's counting towards fulfilling the annual commitment. The Health Services Agency has negotiated this agreement with Kaiser over the past 16 months. This is the only such agreement that Kaiser has signed with any county. The Health Services Agency believes that this is the best negotiated agreement that ensures Kaiser will make impactful community benefit contributions to our county for the benefit of our residents. Therefore, we recommend that your board consider approval of a new access to medical care agreement with Kaiser Foundation Health Plan Inc. and with Kaiser Foundation Hospitals and authorize the Health Services Agency director for a designate to sign the agreement and any future agreements as approved by county council. Thank you. Thank you. All right, we're gonna open it up for questions. I have some questions to start off, that's okay. And I also understand and appreciate that KP has representatives here as well. I appreciate you being here if there are questions. So I appreciate the work on this has been a long road, obviously, since we first started this process. The access to medical care agreements at their core are to increase medical patient access within our county. And so when I was looking at the annual reporting components here, it provided information about the number of physicians that were hired under the recruitment, their names, et cetera, where the money was spent, maybe on community-based organizations on the community benefit donation elements of it. But what metric is there to actually show that it increased access for medical patients? How would we know in the annual reporting that the capacity has actually increased as a result of the agreement for local medical patients? That's a great question. What we're trying to do in the reporting piece is for us to note what percent of what amounts each health system is actually contributing that they're not actually getting any other payment for when we're actually writing off in a way. So for us, that's a demonstration, although we can't count the exact individual's name or where in the county that might be, by us being able to document that they're actually providing some form of grant, some form of charity care. For us, that denotes that they're helping in our community. But we know how many Medi-Cal patients there are in our county. I mean, basically the alliance functionally. So we know, so couldn't we then see whether there's an increase in access specifically of those receiving Kaiser services as a result of the agreement once we effectuate this? Yeah, great point. We are discussing with the alliance the possibility of also looking at the data that they're collecting and what percent or what number of folks are gonna now be able to be served by Kaiser or will refer to Kaiser. So those are preliminary discussions that we're having right now to try to also document this agreement. Do you have a sense, because it was unclear in reading through all the documentation here, I'm not a Kaiser patient personally and so I can't access Kaiser services. I mean, so since it's a closed system by definition, what new Medi-Cal patients will have access to the Kaiser system based on what you were just saying, is it just those with the direct agreement that are being made with the state or is it actually those that right now don't have access to specialty care that are currently members of the alliance? Will they have access, for example, to Kaiser specialists as a result of this agreement? And if not, why not? Or if so, how will we know based on the reporting? Yeah, that's an interesting question, just considering what's going on right now with the state and DHCS agreement with Kaiser. Right now what we understand is that information is being negotiated at the state level with the DHS and Kaiser. So there's gonna be some, we know in the future starting 2024, there's gonna be some Kaiser and DHCS negotiates in terms of a number of patients that will be entering the Kaiser market more concretely. In terms of this agreement, we typically right now are not even doing that with the current health systems to document how the operation lies at. We do obviously see it in the reporting in terms of the charity amounts that go to a community or the income that they're providing in care. But we currently don't break that down even with the 16 contracts. So we can look into that to see what we can do in the future. I mean, the other systems are fundamentally different. They're right, they're not closed systems. So it's not an apples to apples comparison. They're accepting because they don't have a choice. People under the Dominican, that may be in the ER or whatever it may be. And or right now if you're an alliance or a member of any local nonprofit health systems, the only way you have access to specialists is through PAMF or Dignity. And so I don't know how, I mean, I'd be happy to get more data collection on the Sutter slash PAMF and Dignity CommaSphere sort of world. But I think that it's not an apples to apples comparison which is what the, so what I'm hearing is in particular with the change of the state is that it sounds like the agreement should be looked at as a starting point and not an endpoint in particular with the annual reporting requirements. We should probably get more robust data back. And there should be an understanding and expectation on the KP side that this is a starting point and come 2024, 2025 because we're going to have a better understanding of what new or not new medical patients will be taken within our system. I mean, I grew up in Southern California and they're a direct contractor. It's a different system down there. They take a set of medical patients in this area. That's not the case fundamentally. And so what I don't necessarily want is somebody getting credit for physician recruitment, for example, to take patients they were going to take anyway as a part of a direct deal with the state. This is about adding capacity to an a burden system and the lowest, those with the lowest level of access in our community that need the specialty care are kind of relying on these agreements in order to provide that. And that's what I would like to see this agreement do or additional reporting do because I'm not convinced that this actually adds capacity beyond what was already going to be provided through the direct agreement. And I could be wrong, but that if the fundamental need here and the fundamental point of access to medical care agreements is to increase capacity. I don't know that the agreement actually does it and that's what I want to make sure moving forward it does. So I have a final question. I apologize for monopolizing the time here. One thing that is, since it's not an apples to apples comparison, one thing I do think has been expressed to me by a number of the local nonprofit and indigent care providers is a fear that what would happen or what's the plan be if Pam for dignity were to also, these other large health systems would only limit access to those that are linked directly to their health systems, which is something that they have been discussing about a potential need just from a financial standpoint. So when we're renegotiating their agreements which come up in a few years as well, what is our plan? If that were to be something that they did. So if they took the same approach that KP and it became a closed system internally to our county, what would we do for assuring that that medical population has the same access now and an expanded access moving forward? Let me clarify something I know Tiffany wants to add on. Remember that the categories also that we're talking about is for uncompensated care, right? So even though someone might have medic hell, what we're looking for is areas that are not actually currently being billed or paid for. The other category is grants. So in physicians obviously. So this is not just like double dipping in a way. We're looking and computing opportunities where they're actually providing care that they haven't been able to get paid for. So if that's an easier way to think about the agreement as well. And that's the case too with our existing health plans. And you're absolutely right about the direct agreement that Kaiser can enter into with the state. And I know that that was brought to this board last year and the board did request that we sign on to a letter in opposition at that time, but also that legislation did pass with a few modifications. So that is the system that we're operating in and we don't have a lot of control over that. I think my understanding is that the county cannot require any hospital or health system to contract with another. And so what these agreements do, and Jason can correct me. Yeah, we can't require them to contract with the alliance or with each other. But what we've tried to do in this agreement is set up the incentives where Kaiser would be able to count towards this minimum, we put a dollar amount on it that's attached again to their revenues where there would be a minimum contribution and they could reach that minimum contribution by counting uncompensated costs of care. And one of the ways they can do that is through serving those non Kaiser medical right now. That's all medical is not Kaiser in this county. So they could be serving those individuals and the primary way at least in 2022 and 2023 that they would be serving them is at the Watsonville community hospital. And I wasn't like, I'm not trying to intern to an antitrust conversation we're requiring anything like I get the legal component about what I'm saying is that at its course, 50,000 foot view, the purpose of the agreement is increasing access to medical patients. I mean, does it do it? Yes or no, what it sounds like we don't actually know. And so what I'm saying is that then from a baseline standpoint, I think that the board should probably provide additional direction at least on the annual reporting component to make sure that we're getting information that helps inform the renegotiation of contracts moving forward, not just for Kaiser but for the other health systems as well. I mean, I'm comfortable with moving forward with it. I mean, I also think that we need to move forward with something like I get where we are. I'm a realist about that. But I also want to make sure that because of the evolving nature of what's going on at the directory and at the state because of everything from Cali all these other changes that are occurring to the system across the state that we have very directed check-ins about whether or not this agreement is actually increasing access for the most vulnerable in our community. And that seems reasonable. And I think that that actually seems like our responsibility. And so that's where I'm trying to get at.  I just mean that I don't think that the agreement necessarily speaks to that or we just don't know at this point. That was Brian. That's your advisor, Konik. Thank you, Chair Friend. First, I just want to be clear about what are we giving? What is the county giving Kaiser in exchange for this agreement? I mean, is it simply sort of a validation that they're acting in a charitable capacity within our community and in accordance with state law? That's fine. So we don't, we're not getting, let me back up. We're not giving anything to Kaiser. We have existing agreements with health systems to ensure that we're increasing access to care. Because they came into the market in 2018, the board directed us to also create a similar agreement with Kaiser. So in essence, that's what we're trying to do is increase access to our indigent population in our community through an agreement with Kaiser. Right now, I understand the goal. So it's basically just to sort of comply with the intent of state law that nonprofit health systems are acting in a way that expands capacity. I mean, we can't deny any operator or any healthcare provider from operating in the county, right? That is correct. Right. Okay. Now, in determining this 2% that Kaiser would contribute annually towards charitable care and related services, was there a general attempt to make sure that Kaiser's contribution is similar to the other healthcare providers? I mean, that was the general goal. Yes. Okay. Now, I know we have a target of renewing the access to medical care agreements with Dominican Sutter and Watsonville Hospital by June of this year. That's just sort of an aspirational target, right? There's no requirement that we do that. The requirement you provided as a directive where we knew that everybody was going to want to see the current agreement with Kaiser. They were waiting for that. So we anticipate that now that this is public we'll actively start moving forward with renegotiating those agreements. Most likely to be fair with everything we have going on with the emergency response, we'll probably come back to you and request an extension to move through those agreements. Okay. Got it. I mean, I think that's probably a good idea to delay those agreements a little bit too, because I mean, what I've heard and what I see in the memo here is that there's actually a pretty big gap in those current agreements, right? And I'll just read it, which is, both charity and uncompensated care are based on cost incurred for eligible low-income patients not already covered by a current or future form of government-supported healthcare entitlement program such as Medicare, MediCal or MediCruz. So, you know, the health systems, if they're taking a lot, I mean, a lot of Medicare and MediCal patients that's just the nature of our community, right? But if Medicare and MediCal don't pay the full cost of care, we don't count the gap in their costs in terms of this accounting, I mean, is that correct? I'm sorry, can you say that again? Are you saying the dips? Sure, let's just say I'm Dominican and I take a MediCal patient and the cost of their care is $100,000 and MediCal reimburses me $30,000. There's a $70,000 gap there. That's not accounted for in our current access to care agreements with Dominican, right? I believe it is, we'll have to go back and look at the accounting methodology for that and the reports, but there is like a factor that reduces how much they're allowed to count. Okay, I mean, because I mean, even the memo sort of makes it clear that it's not. I mean, what I just read said that it's not. And then it further goes on that the original access to medical care agreements established in 1973 and 1993 have not been updated since the Affordable Care Act implementation as well as the passage of AB204 in 2019, which did require all hospitals whether or not for profit or for profit to publicly report community benefits and more clearly defines community benefits, including the unreimbursed cost care of unreimbursed costs of providing services to Medicare or Medicare beneficiaries. So basically, and I think it was what, yeah, 2019, AB204 added this clarification at the state. And maybe this was in the state report that the healthcare providers are providing. It is in the state report. But not in part of our access to care agreements. So I mean, my basic concern here is that there's possibly a very large gap in terms of what we're trying to create a level playing field. There could be a fairly large gap in terms of what the current healthcare providers are actually doing for our community and what we're seeing on paper. So when you say, okay, Sutter is providing $2 million worth of charity care a year, that doesn't account for all of the unreimbursed care they're providing to Medicare and Medi-Cal patients. And I think that could be significant. So for the end, I'm sorry, please, I didn't rose your attention. And I mean, as chair Friend was suggesting, I think the concern here is that if Kaiser has effectively created a way to block many Medicare and Medi-Cal patients, I mean, patients from receiving care under their system, that the existing healthcare providers in our community could effectively say, well, we have to do the same to stay competitive. And maybe we can't deny them, they can't deny them from the emergency room, but certain physicians could decide they're not gonna take those patients. And so I think that's why, again, to chair Friend's point, it's important to look at how many folks are being helped who are on these government insurance plans, net across our community as the situation evolves. Those are all my comments. Thank you, Supervisor McPherson. Do you have anything else? No, Supervisor Cummings. First, I just wanna thank you all for your hard work on bringing this agreement to us because it sounds like there's been a lot of work that's been put into this. And the intent is really to try to get us to help expand medical care to some of our lowest income residents. And based on what I was able to read in the staff report, this agreement will also help to really expand medical care in South County as it relates to Watsonville Community Hospital and hopefully bringing more specialized care into the community. I just wanna acknowledge the work that you all have put into this. I did have a question because I do share, the fact that this is a new program, this is a new agreement, I do share some of the concerns expressed by Chairman Friend and Supervisor Koenig really around tracking how we're able to track who's receiving benefits over time. And I know that part of the direction is that we more or less we authorize the Health Service Agency Director or does you need to sign the agreement and any future amendments. And so I'm just curious are there, what is anticipated in terms of how this might change and what kind of amendments we might see made to this over time. And have we seen changes to previous agreements because I think that with this being new, having this come back to the board so we can track how it's progressing over time would be helpful for us to kind of, to be able to see that it's being effective and that we're understanding how it's rolling out. Yeah, it was our intent from the part of point, if you can note that we knew we had to come monitor this agreement and come back to the board. We come back to you and report annually on all the health systems and their contributions. We know that some of these have been in place since the 1970s and 80s these agreements. So we're aware that so much has changed in healthcare delivery, the state, the federal government coming up every year, obviously with new policy. So that's our intent right now. You can see clearly that we'll be working closely with Kaiser coming back in 2025 is around the corner for us. So truly next year, we kind of sit down all together and start looking at this agreement and seeing what the changes might be that might be revisited. The discussions with CEDR and Dominic and Watsonville will occur and all the feedback that you're providing to us will use it to think about how we will mold those agreements as well. With, there is a lot of opportunity and limitations at the same time. And so we'll meet your guidance and advice as we move forward through these to ensure that you feel it's actually also beneficial to your residents, to your constituents here in the community. So any future feedback that you have, please let us know more collecting it as well to think about specifics that you wanna see in the future agreement. I can lose my comments, thank you. Thank you. Suvez or Hernandez? Justin mentioned some of the contributions that Kaiser made in South County specifically to make sure that we keep the hospital low and continue with the hospital district. So I'm appreciative of that portion of that. And I was listening to supervisor Koenig's comments but one of the things that I think that I think all the hospitals are in that similar situation too where that 70, 30 gap exists for all of them. And it's difficult to look at those state regulations that kind of set those criteria for hospitals and for us. It kind of reminds me of those the public comment earlier when they talked about our archaic planning regulations that we had from the 80s that we've got to change but some of those are state regulations that we have and it's true, we got to change those eventually but some of those are not at this dais to change but at the state legislators dais to change. But I think that in terms of equity, I think in terms of charitable contributions I think that that's one way that we can look at Kaiser and push them to continue to contribute in that way as well. But I think those are my comments. And I appreciate what they've done in South County in terms of the hospital district. Thank you supervisor McPherson. I really appreciate the concerns that have been raised by the chair, a friend and supervisor Koenig. The fact of the matter is this type of arrangement has never been done before. And I'm not sure, well, we're gonna have to just look back two years from now or sometime in the near future and say, okay, this is good or this is not so good. I'm balanced. I think this is better than what we have without coming to any agreement. That's just my basic thought at this time but I'm open to hearing any public comment as well. Thank you. I agree. I mean, I think it's a starting point. We'll open it up for the community. If there's members of the community they'll like to address us on this in chambers. Yeah, good morning. I must admit where I was thinking I was gonna have difficulty staying on topic but I wanted to just quote some stuff.  What is the county giving Kaiser? What are the medical endeavors for our community? Oh, I could really go anywhere with this. So it's just great to be in observation in quite the last couple of days doing research. I mean, I suppose I could talk about the effects of what hospitals like Kaiser have been promoting and how they've actually been affecting the inhabitants. I'll just read one title. MNRA vaccines are a sham. People are being injected with a nanotech. Now I spent quite a few hours going through over a thousand pages and just printed up some but who cares? I wasn't actually finding what I was looking for and I had to do other things. So I really find it fascinating how beguiling what the situations are and I'm just gonna read a definition of the Delphi technique. Our objective is to get the answers we want and make citizens think they're participating in the public process all the while the decisions have already been made beforehand. You know, that's just not deluding the public. It's actually deluding you members as supervisors who are really under the control of the County Manager, Collors Palacios. So what can we actually do with what's going on with what seems to be fraud? You know, I like this definition of Western medicine as petrochemical finance sickness over health, profits over cures, written by a doctor who after 20 years was no longer a doctor. She wrote a book called Medical Mafia, 76% of the people trust their doctors, only 6% trust their politicians and the doctors are run by the politicians. I'm here to witness change. Thank you. Anybody else in chambers like to address us on this item? Thank you, Becky Steinbruner from rural Aptos. I want to thank you Supervisor Koenig for asking the question, what is the County giving to Kaiser for this? That's been my question too. And we're not at all talking about the huge medical complex that Kaiser has in the works to build with a four story parking garage adjacent on Soquel Avenue. That seems to be stalled. And I was told that Kaiser actually wanted to buy Watsonville Community Hospital was discouraged from doing so. That delay caused them a lot of problems with their permitting for their plans to build a huge hospital in the Mid County area. Why are we, what are we giving them now? And why is there no talk about this project and how that's going to fit in with this agreement? I appreciate Chairman Friend's persistence in wanting better data tracking and actual proof that this agreement will benefit those who are not able to pay. I'm a little uncomfortable that Kaiser will be given the ability to use the $3 million that they gave to the Watsonville Hospital buyout or the cost of consultation and administration. That's a very vague condition. And if we allow Kaiser to write this off essentially their donation to Watsonville Hospital will Dominican and Sutter who also contributed large dollar amounts also want this favor. How will this affect the Kaiser members that are paying for this Kaiser's ability? If this is the only county that Kaiser is making these agreements with are their cost of membership and their level of service going to be changed? Thank you. Thank you. Anybody else in chambers? Okay, seeing none, Madam Clerk, people online? Yes. Thank you. Larry, your microphone is now available. Can you hear me okay now? Yes. Okay, yeah, this has been a great conversation. And I did, I appreciate that the board had an opportunity to receive my email yesterday where I described my 40 year history in the county. I'm a retired physician on a multitude of state boards. I've been on the Alliance Board with Monika and Survisor Friend for over 15 years. Let me just say that we have a crisis in access in this county. Crisis for not just MediCal and uninsured but Medicare patients as well. So Supervisor Friend's question of how will this help access? This will profoundly worsen access for the patients in our community because as I outlined in my notes, the contributions from dignity per California law which Tiffany misrepresented which includes unpaid costs of government programs. Dignities and Sutter's contributions have extended to their entire network is close to $100 million and is about 20% of their operating expenses or revenues. And you're looking at a 2% target for Kaiser. And again, for Monika, the Kaiser came in 2017 and for Supervisor Hernandez, there's 90,000 MediCal patients. They did the right thing by Watsonville Hospital because they need that hospital in order to sell commercial insurance in this county but they have zero MediCal patients. Six years into their journey in Santa Cruz County, they are focused on commercially insured patients where the profits are. They take no traditional Medicare patients. They here to four have taken no MediCal patients. And the most important thing I think that Supervisor Koenig was getting to is in kind contributions and charity are nice but they are dwarfed by the losses in the caring of Medicare and MediCal patients. And that's for the $100 million that Dignity and Sutter are contributing to this community. And you are going to the reason why, I see I'm at two minutes, happy to answer questions.  And you'll be sending a message to the physicians of Dignity and PAMF, stop taking MediCal patients, stop seeing traditional Medicare patients behave like Kaiser. Thank you, Dr. Yigitaldi. Thank you, Dr. Yigitaldi. Is there anybody else on Zoom? Call an user three, your microphone is now available. Thank you, Gareth. Thank you to the previous speakers, especially the doctor. We just heard saying that this will worsen access. That fact seems reason to vote this down. And as I was listening, I was thinking, yes, you've done a lot of work on this, but how convoluted are so-called healthcare system is, and the insurance companies make off with all this money, I feel like insurance companies should not be in the healthcare system at all. I believe we have a right to health and a right to care of our choice, like chiropractic, occupancy, et cetera, should be covered. And recently, I saw the film again called Sicko by Michael Moore was made over 10 years ago, but he showed how sick our healthcare system is. And maybe some of you saw it, it's worsen again because it shows there are other countries providing for health in more ways to everyone than the United States. He went to Canada, England, I forget about France, I think, where they have a healthcare system where people are treated, Cuba, whether they have money or not. And that's what we need everybody to have access to genuine healthcare and not having the insurance companies in the picture and refusing care to people and raking in the profits and this item on the agenda seems to just be giving more profits to Kaiser. I think it's worth voting, no, thank you. Thank you, Ms. Garrett. Is there anybody else on Zoom? We have no further speakers, Chair. Thank you. We have an additional speaker in chambers. Good morning, welcome. Good morning, Supervisors. Joe Foster, Public Affairs Manager with Kaiser Permanente here in Santa Cruz County. Wanted to say thank you all for considering this item and wanted to reiterate and sort of piggyback on what Chair Friend was saying about this being a starting point. And I think it's really important to point out, as we've shown in the presentation, that there'll be aspects of this revisited, mutually revisited by the county and Kaiser Permanente moving forward. We're really happy to, you know, a number of years have gone into this, a lot of work on staff's part. We certainly appreciate that. We mentioned earlier, or Tiffany mentioned earlier, Valerie Lomax and Evelyn Tran from our team that worked on it. They're here with us today. Just wanted to recognize them for all their hard work, but, you know, we took this process very seriously as did county staff. And we're really happy to arrive at this point and look forward to the serving out the duration of this agreement and looking into ways to continue approving it as the ever-evolving local health care industry continues to grow and change. Thank you. Thank you, Mr. Foster. Was there anybody else in chambers? Okay, seeing none, we'll bring it back to the board. Supervisor Koenig. Thank you, Chair Friend. I'm gonna go ahead and propose, make a motion that we approve the access to medical care agreement with Kaiser with an updated term, that's section five of the agreement, to expire upon the execution of new access to medical care agreements with Dominican, Sutter and Watsonville. And that the new agreements for all healthcare providers include a definition of charity care that is consistent with state law by including unpaid cost of government sponsored healthcare programs and include reporting requirements in the new agreements on the total number of Medicare and Medi-Cal patients served. And that we also pursue access to medical care agreements with the physician medical groups. But there's a motion, is there a second? I'll second that. Can I ask a council of what the mechanics of modifications to the contract would be? Yeah, the mechanics would be first, we'd have to talk to our contracting partner Kaiser to find out whether they were amenable to those changes because at this point Kaiser has agreed to what's before the board. So if the board wants to make changes, then we'd be back in the negotiation base. And so we would basically take it back to Kaiser to discuss these changes.  Yes, I understand and appreciate that. And again, as has been said, appreciate all the work that has been done both by county staff and by the Kaiser team on arriving at this agreement. And as has been said multiple times, this is a starting point. And I think that really that's what I'm trying to encapsulate in my motion is that the term, we will, let's absolutely move forward with this agreement today. It's certainly better than not having an agreement. And, but that we make it explicit that we're going to, that this contract will expire and we'll reevaluate. And of course we'd need a new contract ready to go upon the time that we update our agreements with Dominican Sutter and Watsonville. I feel like that's really the best way to make sure that we've created a level playing field here. And of course, as was said, we're not required to update those agreements at any specific time. I certainly feel willing to give you an extension beyond June of this year. I think they probably would push us into the timeframe that's already encapsulated in this contract of 2024, 2025. This contract that we have before us today says that the agreement will be reevaluated in 2025 anyway. So I think I'm just a more explicit link to that reevaluation happening at the time that we look at all the access to care agreements in the county. So the board could, the board could, if you wanted to give additional direction to staff to consider those items when it comes back with another version of this contract later or amendments later, is that making sense? That's exactly right. And that's what was explained in my motion is that this particular agreement we would, I'm moving that we adopted today with the exception of the change of the term. Yeah. But then you're not adopting the agreement because we're changing the term, that's the issue. So the question is you either adopt as is and then provide additional direction, which I'm all for all the additional direction, but we wouldn't be actually adopting the agreement because we'd be amending the agreement because the term is part of the contract. That's the challenge. Okay, understood. I mean, of course, all the other points that the direction would be additional items to be considered in the future. Supervisor Hernandez. Cern about this, you know, I think staff really spent in part of CAO's office a tremendous amount of time with this agreement and to synchronize the contracts with three other agencies, but three other hospital systems is gonna be even more time consuming to do it all at one time for staff. I don't know if they have the capacity to be able to negotiate three contracts and do their work for contracts, big major contracts at one time. I don't think they have the capacity to do that because I'm sure this took them a good amount of time the two offices, CAO's office and health to do this. So it kind of concerns me if they're gonna be able to do it as well when they're staggered or synchronized to do all five of them or four of them, all the systems together in one big contract just makes it difficult for them, I think. Are you supportive of the general concept of the additional data reporting and the need to ensure that we actually make sure that this agreement adds capacity on the MediCal patients? Yes, I mean, I even wrote, I wanted to see if we can make sure that we, if there's any changes to the agreement that are significant in state or federal funding formulas or perhaps legislative or regulatory or policy changes that had come back to us, right? Where we can amend it, where we can amend it, right? To make it more fair in essence, but I think putting it all on staff and one lump sum to work on is kind of a big load, I think. No, I understand that. I mean, we can't literally amend anything. So the point, what we're trying, I think to do is to create a system by which exactly what you're talking about, well, A, one to get more information to make sure that it's serving the population that disproportionately is in our two districts, by the way. Number two, that if there are changes, as Mr. Foster said, this is an evolving system that there be flexibility and continued negotiation in advance of the 2024 and 2025 timeframe. Justin brought up that there is that mechanism, but it goes to the director, but I think that he also alluded that it can come back to us. If he was asking if it can come back to us, I don't think it was answered, but we can say it can come back to us if it's a significant change that's happening in the contract. Okay, I mean, so I think the mechanism is the annual report to allow for that opportunity is what I'm saying. We're getting a yearly check-in, but we can't unilaterally amend is what I'm saying, this is an agreement between two parties, I mean, it's a standard contract. But we can telegraph the expectations and what it should say, right? And that's what I think that we're trying to come to an agreement here. That's the advisor Cummings. Yeah, I just want to leave base point to what I was bringing up earlier within the language it says, authorize the health services agency director does you need to sign the agreement and any future amendments as approved by council. And I think there, if it's non substantive amendments, then having the health services director do that, I think makes sense. Given that this is new, if it's a substantial change that's going to occur, having that come back to the board would make sense. And that's why I was asking how many times we've seen substantial changes to these agreements occur in the past, being new to this, I'm not sure, but it seems like that might help us get to really understanding if there's major changes rather than just that being a black box for us having the authority to make those changes. But I did want to also say that just given the extent of the amendments, it's hard for me to really be able to understand exactly what we're doing without seeing that in front of us. I think minor changes to the direction is one thing, but then, if there's a way for us to be able to kind of lay this out, because I really want to try to understand what supervisor Koenig is proposing. And I know that some of it incorporates being able to get updates on whether or not this is effective, but what was stated was really hard for me to just kind of internalize as it was being said, because there was a lot of proposals to that amendment. But similar to what the County Council was saying and I'm not sure what direction we can go, but if today we're adopting this contract, being able, knowing that if there's any major amendments that will come before the board, and then we can have some of these other pieces considered over time as we're making these other agreements, that sounds like something that we can probably move ahead with. But I think for me, also those other recommendations are something that I really want to better understand because they came really quickly. It seemed like they were major changes and I'd like to better understand what's being proposed. And so for me initially, I was thinking, I see a lot of changes in the system for behavioral health. I don't know if you've seen the letter that came out from the governor about housing and behavioral health that's coming out, but that's what I was thinking about. But Manu made me think about medical funding and changes that might come up in that. But I think that the yearly update, I think that's because it's gonna come in a policy, the yearly cycle for the policy changes that come up with the federal government and the state government. So we can align those amendments with that that come up every year and we can make those changes as they come every year. And that'll be the updates that we, we'll begin now, this is the start point and every year we can update it and make it better every year when there's changes that change the agreement, right? If there's changes that are significant. So let me, let me just try here for a second if I may supervisor McPherson. I mean, I think that there's unit and we should get to unanimity on this by the way, this really matters. I mean, so I think that there is unanimity that we move forward today with the access to medical care agreement. I think that that's the stylish and we'll have to make sure that's clear in the motion. I think that there should be unanimity on the fact that any sensitive amendments come back to the board of supervisors I think that that's understood. Well, we're just now looking for unanimity is ensuring that we have an understanding of what the additional amendments are of additional information and guidance to staff when they're in renegotiation as to what we would like them to prioritize. I think that's really what this is. And I think that we're actually, actually what I hear is we're actually exceptionally closer as to be an understanding of what that is. So if you don't mind restating that when also with sort of that framework and then I will. I agree with your comments. This is a complicated issue. Health care issues always are. And this is a 10 year agreement. Is that? So The 10 year agreement with coming back on 2025 to revisit. Yeah. Okay. I just, I think we're, this is unusual and it's a step in the right direction. So I would go with the basic staff recommendation with the addition of what supervisor with chair friend said that we can review it. But I don't want, I made the second. And I think, I don't know, I'll hear from supervisor Koenig, but I'd be willing to withdraw that and follow with the direction of what supervisor or chair friend said. Well, it's possible that we may be there anyway. Go ahead, supervisor Koenig. I guess I wanted to start because we're entering around this idea of revision, right? So, I mean, the current contract I see in there that we agree to reevaluate in 2025, but there's no requirement to do so, right? I mean, there's no requirement that Kaiser ever accept any of our proposed revisions, right? Until the agreement ultimately ends in 10 years from now. So I'm reading that wrong. If the board wants to make changes, we would launch into that discussion with Kaiser. If the board is not satisfied with the changes, obviously the contract, we can modify it at that point or come back to legal counsel to figure out the best way to move forward with it. Right, so we can propose changes, but that doesn't necessarily mean that we'll be accepted. Kaiser will have to, we will have to renegotiate with Kaiser on those changes, yeah. Right. It's a continuing conversation on what community benefit looks like, right? I mean, I guess that's the only guarantee we have, right? Yeah, and if we come to a place where we disagree at some point on what community benefit looks like, then we look at what our remedies are. Okay, I don't love that, but it might be the best that we can do today. So let me explain the other parts of what I'm talking about here, which really get this suggestion that all new agreements for access to healthcare, to medical care include a definition of charity care that considers uncompensated costs associated with government-sponsored Medicare and Medicare, Medicare and Medi-Cal healthcare programs. So again, this gets back to the example. Someone goes to, let's say, it's the Watsonville emergency room and they have $100,000 worth of care provided to them. That's the cost to the hospital. Unfortunately, we haven't seen Medi-Cal keep up with the cost of care. And so the hospital may only get $30,000 back. So now they have a $70,000 loss, but our current access to medical care agreements, they were written in 1993, back when that gap between what the government-sponsored insurance was paying and the cost of care was not as big. This was not a big issue back then. And so, but today it is, and we're not even really accounting for it in our agreements. And so, I mean, when we hear that Sutter is providing $2 million a year in charity care, that's not considering that gap between whenever they help Medicare and Medi-Cal patients between what they're getting paid and the cost of service. And so I think it's important if we are gonna actually look at who is providing what to people in our community that we make sure we do some accounting of that. And that's actually state law now. I mean, as you heard, these healthcare providers are providing those statistics to the state. They're just not providing them to us because the state's law was updated in 2019. Our contract agreements were from 1993. So all I'm asking for is that in the future, when we consider new access to care agreements with all the healthcare providers in our community, that we make sure we have reporting on that. This is data collection. I mean, it's not... Different reporting to us than they do to the state? Is that what... That's my understanding, yes. I'm just wondering if maybe County Council and County staff can weigh in on this just a little bit because I'd like to just better understand. I mean, I think I hear what Supervisor Koenig is saying, which is that we clearly identify charity care in our agreements. And then we try to determine what services are being provided by that care. And then when there's uncompensation for services that we understand what that number is. If I'm getting that correctly, maybe I'm not. I know the world we're in now with health is so complicated and there's so many needs. And we are in a situation where all of us are struggling to recruit including these health systems, specialty care just seems to just be eroding every day in our community. And I wanna acknowledge that and also acknowledge that the request you're making is actually very different in many ways. And it does tie to the current agreements you have with these hospitals. It sounds to me like you wanna understand a little bit more as what are some of the gaps that our indigent communities are experiencing in care? What do they look like? What are we not accounted for? And that obviously is information we can capture for you. And then there's an agreement that we have with health systems that you are trying to ensure that our population has access to care. As insurance continues to grow whether through Medi-Cal as we know, and now in California we're even ensuring those who are undocumented. This will continue to be an issue in our community but not as broad. So I wanna separate the issues that we're confronting as a system, as a community with the agreement that you have here and also remind you that what you're requesting makes a lot of sense and 40, 50 years ago a lot has changed. So I encourage to adopt the recommendation we're proposing and then set a new recommendation for us to do the separate research that you're looking for and then come back and assess as we're reporting to you on these agreements annually and we're coming to you to also have you approved the new contracts, whether or not it makes sense after you've seen the data that you're requesting because it is separate and I know it goes together. So I'll pause there and see if Councilor Tiffani want to add anything else. I don't have a further recommendation but I can extrapolate a bit on the example that first district supervisor Koenig brought up if you want me to. Okay. So in the example where there's a $100,000 cost for a service in the emergency department and let's say Medi-Cal or Medicare only reimburses 30, you said 30,000, so 30% and there's the 70% gap. Stuff like that does exist. It is reported to the state but the difference is what the hospitals report to the state and Kaiser doesn't have to report this in Santa Cruz County because they don't have a hospital here. So what the hospitals report to the state there isn't like a clear definition of what that ceiling of $100,000 is. So the hospital says, well, the service costs $100,000. It's essentially their charge master price. What we've tried to do in the agreement that's before you today on Kaiser is actually put a ceiling on that. So it wouldn't be 100,000. It would be what Medicare reimburses plus 20% which we feel is more accurate of what the true costs are. So we're starting to get to what you're describing and I think the further direction will help us get there on a future reporting. Yeah, and I want to appreciate that. You included that element in the agreement with Kaiser to try to get at the true cost of care. Two votes are coming. I'm just wondering in terms of moving forward because it sounds like, I mean, I think this is especially as a new supervisor something that I would like to maybe have more background on in terms of where we're going with these other contracts. And so I'm wondering based on the feedback that you've received, if there's an opportunity for us to have this come back. The second part of this come back is another item that we can dive more deeply into and that the public can have a better understanding of because it sounds like the contract, the second round of contracts to the contracts with Dominican and PAMP or actually maybe I should ask this question. When are we expected to see those contracts? We were just discussing that.  It's one of the directives you provided to us. Depending on the motion that goes, we can, the goal is for us to start those contract negotiations now. I heard a little bit of motion of potentially coming back in 2025. So it really does depend on, you know when the board wants us to come back. I will ask that if you please can give us a few months because it does take some time. Depending if you separate these agreements, it will be ideal or if you're gonna lump them together as Supervisor Hernandez had mentioned, it will be a little bit more complicated. So for us, as soon as this is agreed upon, we'll go back to the other health systems, start negotiations, but as you notice, it definitely can take months, two years to get to something that is agreeable. We will walk the board through the process along the way having, you know, one-on-ones with you, giving you updates and then coming to you for final approval once we have some form of draft agreement. Let me just say that I think that we're fine with recommended action with that modification of when something comes back to the board, where there's inadequacies on the annual reporting, quite frankly. So if you want that outside of this agreement, I totally respect it. This is also the time for us to make that direction to you though. So that's why we're having this discussion. So I think that the fundamental question will need to be asked whether this improves access to care for low-income patients in our community, period. And the annual report doesn't actually do that. And so what I think what we're trying to do is get information back in that annual reporting situation. And if you feel that it should occur outside of the Kaiser annual report, and it should just be a yearly access to care report, that's fine too, because we can provide direction at that time writ large to the Kaiser agreement as well as the other agreements. But I think that there's a lack of satisfaction from the board about where there's a concern that the agreement as written may not change the trajectory of access to care or indigent care patients in our community, period. And we want to make sure it does. That's the point of what we're here to do. And I think that so too to those that are actually engaging in the agreement, which is why we heard a commitment publicly from the organization to be willing to make this an iterative and baseline process. And so what we're looking for is just to try and come to a motion that does exactly that. And what I would recommend is a motion that adopts the recommended action with that modification of substantive changes coming back to the board. And I think that you've heard some of the requests of what we want in a robust annual reporting process. And if you need it enumerated, we can enumerate it. If you feel like you could repeat back to us some of the things you've heard and we can consider that satisfactory, we can also go down that road. I mean, I'll leave it to the board member. But we still have a motion and a second on the floor that we need to actually address either we need to vote on this specific that needs to be withdrawn or modified at this point because we're getting to that sort of that point. But I think that's where we are. Survisor Koenig? Sure, so I think as Director Morales pointed out, we have this sort of June 2023 date for renegotiating the existing access to medical care agreements with the other three major providers. Now, whether or not we act, I mean, and that's a board directive. So we're probably, especially if there's substantive changes recommended to those agreements, we're probably gonna have to push that date out. Now, I think when that request comes, it could be an opportunity to look again at the situation as requested by supervisor Cummings. So, yeah, but at the same time, it's helpful. I feel it's helpful to have in our motion today this direction of what it is that we're looking for ultimately in some of those new agreements and also in terms of reporting requirements. Okay, I think we can simplify this if we take the direction of staff plus an annual access to care report where more issues will come up. I mean, it'll simplify the motion, I think. And that's what I'd be supportive of as well. I'm happy to modify, suggest a modified motion. Why don't you just withdraw the previous one? I'll withdraw the previous motion. All right, and then go ahead and start again. Okay, I will move that we approve the access to medical care agreement with Kaiser and that we pursue new agreements with many consider in Watsonville and that those new agreements include a definition of charity care that is consistent with state law by including unpaid cost of government sponsored healthcare programs. And that way they include annual reporting requirements on the total number of Medicare and MediCal patients served. I'll second that. Okay, so let me just throw something in here, which is just that I believe that there was a desire by the board to ensure that any substantive agreements in this recommended action come back to the board of supervisors and not that we're not delegating the authority. So that's just a modification to that recommended action. Yes, that's amenable. And switch to the last one. Please. And that report comes with the annual report you're saying? The report with the other systems? Yes. Okay. Questions. Everybody in agreement? Does the clerk in agreement or understanding? I should say. Yes, I believe we understand. Thank you. You can let us know. Thank you. We good? All right, but then we'll, if you could do a roll call vote, please. Okay, and to clarify, I have this motion coming from Supervisor Koenig seconded by Supervisor McPherson. Yes. Thank you. Supervisor Koenig. Aye. Cummings. Aye. Hernandez. Aye. McPherson. Aye. And Friend. Aye. Chair Friend, if I could just comment. Thank you for your vote. I just wanted to congratulate the board on taking the access to care of medical agreements so seriously and having this precedent set because my understanding is pretty clear that we're the only county in the state that does these agreements. And this is the only first time that Kaiser has ever signed an agreement like this with anyone in the state. And I know the agreement is not perfect. As he said, we're coming back. We're going to make them better, but it is an achievement. And I think it is a precedent that this board has set in trying to increase medical care for the most needy in our community. So I think I know there's often not clear to get the context. And the context is that your board is showing leadership on this issue statewide. And I want to make sure that you understand that it's not a perfect agreement. We agree. The staff has done a great job in negotiating it, but it's also a leadership position that you are taking statewide on this very issue. Thank you. Thank you, Mr. Process. We have a 1045 scheduled item that we're going to move to right now, which is item 12, which is the Board of Supervisors shall recess in order to permit the Board of Directors of Santa Cruz County Flood Control and Water Conservation District Zone 7 to convene and carry out a regular scheduled meeting. Madam Clerk, do you need, I don't think there's anybody additional from the, is there? Everyone will be attending in person that I'm aware of. Okay. They just go through that plan. Okay. All right, if we could have a roll call, please Supervisor Hernandez is here. He's just stepping out for a second. Go ahead. Certainly Supervisor Apologies, Director Koenig. Here. Cummings. Here. Friend. Here. McPherson. Here. Colbertson. Billisich. Clark. Present. And noting that Supervisor Hernandez, Director Hernandez is returning to us shortly. I'll make sure that we include that information when he returns. Okay. I had also received information, maybe Mr. Machado or Ms. Fatui would know. I think that Ms. Billisich, hasn't there been a change in the city of Watsonville for that representative yet? So I think it's Vanessa now if I'm not mistaken. Is that correct? Okay. But I don't see Vanessa here either. So we'll count it that way. All right. So we'll move on to, are there any changes to say is it agenda? No changes today, Chair and thank you. All right. So we'll open it up for oral communications. This is an opportunity for members of the community to address us on items not on today's agenda, but within the purview of zone seven. Any member of the community would like to address us on oral communications. Okay. We'll close our all communications. We'll move on to item four to the approval of the zone seven board meeting minutes. Are there any changes to the minutes from directors? Seeing that, any member of the community would like to address us on the minutes? All right. Bring it back to the board for action. Move approval at the minutes. Second. Move a motion from director Koenig a second from director McPherson. If we get a roll call, please. Aye. Director Cummings. Aye. McPherson. Aye. Aye. And friend. Aye. That passes. We'll move on to action on the consent agenda. Are these are items six through eight? Are there any questions on any of the items on consent? Any member of the community would like to address us on consent? Bring it back to the board for action. You want to make a motion? I make a motion that we accept the consent agenda. Perfect. Second. All right. We have a motion from director Clark, a second from director McPherson. We have a roll call, please. Director Koenig. Aye. Cummings. Aye. McPherson. Aye. Friend. Aye. And Clark. Aye. Welcome, by the way. We'll move on to the first item of the regular agenda, which is item nine, which is to consider nominations for the election of the zone seven board of directors, chairperson and vice chairperson is outlined in the memo of the district engineer, Ms. Fatui.  I think the microphone button, there it go. I think so. Yes, this item is in front of you to nominate the chair and vice chair for the zone seven board. And if possible, we'd like to add some history to consider while calling for the nomination, which is the ongoing transfer of the Pajaro River Flood Control Management Project responsibility from zone seven to the newly formed Pajaro River Flood Management Agency and having the current chair keep that role will help in the smooth transitioning of the process and achieving the projects implementation goals. There are four zone seven staff is recommending that the incumbent chair be nominated for another term. Staff also recommending for the vice chair be filled by the board of city of that was involved representative. All right. Are there any questions for board members on this? Any member of the community to address us on item nine? I'll bring it back to the board for action. To move recommended action. I second. Great. We have a motion from director McPherson to second director Clark. If we could have a roll call, please. Director Koenig. Hi. Cummings. Hi. McPherson. Hi. Clark. Hi. Friend. Hi. And director Hernandez who's joined us 1113. All right. That passes unanimously. Move on to item 10. Improve the amendment to the 2023 zone seven board director's meeting schedule replacing the May 30th, 2023 meeting with a May 9th, 2023 meeting is outlined in the memo of the district engineer. This is pretty self-explanatory. Is there any director has any question on this item? Any member of the community like to address us on this item? Okay. We'll bring it back to the board for a motion. I'm so sorry chair. Yes. We do have someone online who'd like to speak. Okay. I apologize for that. Dr. Bill said your microphone's now available. Thank you. Good evening. Good morning. I just wanted to ask you about the May 9th budget meeting at 1045. Isn't that usually in Watsonville? It's going to be held in here. That's was decided on this council before. It's going to be held in this chamber. But there still is a meeting in Watsonville, correct? I believe in October. In October, yes. I thought we had a two and two. Two in Santa Cruz and two in Watsonville. I think we've had both director, sorry, Dr. Bilicic historically. And then this is proposing a change to have that move to Santa Cruz. Well, it certainly is up to you. But I noticed that there were two usually for Santa Cruz and two for Watsonville and the budget one was had been in Watsonville. So just a consideration. Thank you. Thank you. And Dr. Bilicic, I apologize that I didn't go to Zoom initially. Did you have any oral communications that you wanted to make because that was my mistake to not open that up? I'm fine, thank you. Thank you. Okay, so bring it back to the board now for action on item 10. Did we have a motion to second on that move approval? Second. All right, we have a motion from director Koenig and a second from director Hernandez. If we could have a roll call, please. Certainly, director Clark. Aye. McPherson. Aye. Koenig. Aye. Cummings. Aye. Hernandez and Friend. Aye. And the last item on our regular agenda for zone seven is to adopt a resolution confirming benefit assessment rates for the 2023-24 fiscal year to adopt a resolution setting hearing on May 9th, 2023, beginning at 10, 45 a.m. or thereafter. If you consider the 23-24 benefit assessment rate report and take related actions as outlined in the memo of the district engineer, we have the resolution adopting benefit assessment, the resolution setting the public hearing and the notice of public hearing. If we could have a report, please. Yeah, thank you, chair and directors, Matt Machado, your district engineer. And so just briefly I wanna cover that this is an item that we bring back to you annually. Our staff computes this benefit assessment rates. This year's assessment rate is simply increased by a CPI, but the CPI is at a maximum 4% due to the way our district was established back from the 91 district engineer's report. And so the recommended action today is to include a CPI limited to 4%. And your chair already listed the recommended actions. And so staff is here to answer any questions that you may have. Thank you. Are there any questions from board members? Any member of the community would like to address us on this item in chambers? Member of the community on Zoom? Yes. Dr. Bills at your microphone is now available. Thank you. Is this the standard zone seven that's on the tax bill? Is that with the assessment that we're talking about? Yes, it is. So it's nothing to do with the individual assessments that people are already paying. That's a different, if you're referring to the assessment that was approved, that was through a different agency. This is the zone seven, not the PERFMA vote. Okay, thank you. All right, anybody else on Zoom? No further speakers, chair. We'll bring it back to the board for a motion. So moved. Second. We'll move a motion from director Hernandez for the recommended actions. A second by director Cummings. We could have a roll call, please. Of course, director Clark. Aye. McPherson. Aye. Cummings. Aye. Hernandez. Aye. Friend. Aye. Thank you, noting that director Conan Kiss stepped away. Thank you. And thank you council for sitting in on this. That will close our zone seven meeting. Thank you for coming up by the way for this. We truly appreciate it. And we will move back to the regular board of supervisors meeting, which is item eight. Item eight is to consider a report on purpose scope and financial details of the Boulder Creek water quality and recovery project is currently proposed and direct staff to return on or before October 17th, 2023 with a continued status report, implementation strategy and further budget details. As outlined in the memo of the director of the office of response, recovery and resilience. So we have the agenda item board memo as well as two different attachments. And I believe our primary presenter is Mr. Reed, David Reed, who's the director of OR three, Mr. Reed. Welcome back. We appreciate your work recently with all the storms as well. Thank you, chair or for the opportunity to bring you all up to speed on this interesting opportunity to build resilience in our community. What we call the Boulder Creek water quality and recovery projects. Just quickly on an agenda and the meeting purpose really, as I said to bring you all up to speed on this project but more importantly for the board and the public to better understand how these types of resiliency projects need to be framed in our community need to be understood in the changing climate that we live in so that we can better position ourselves to address the needs and concerns of our community both urban and rural. So we'll be doing a quick dive into the history of the project and the Sander Inns Valley Sewering and then go over the preliminary project goals, scope, cost funding and discuss next steps. So the history of Sewering in the Valley is longstanding and I won't go into it in great detail but I do wanna say that the Sander Inns Valley watershed supplies water for over 95,000 folks in our community. And during the late 70s, early 80s, the maintenance of those septic systems, those onsite water treatment systems, OTS caused significant degradation of the water quality in the Valley. At one time, the regional board put a moratorium on new development in the Valley and out of that process was the first attempt to sewer or install sewer in the Valley. This newspaper clip from 1984 indicates that that initiative failed for a host of reasons. The main one being the fear of growth inducing development because of Sewering. So I just wanna set that as the context as we move through this, that it failed in the early 80s because of a fear of more development. There are still a tremendous number of onsite water treatment systems in the Valley, many of them predate code, many of them have issues that are now addressed in the newly adopted lamp that you've all been aware of. In Boulder Creek specifically, big development in the 1960s around the Boulder Creek Golf and Country Club created CSA 7, which is a sanitation district serving the residents up there around 250 or so connections. Another subdivision in the late 60s created Fallen Leaf neighborhood, which is Big Basin Sewer, which is another small sanitation district in the Valley currently experiencing issues. In the early 90s and there were two attempts to explore Sewering again in the Valley, those attempts also did not see success in moving forward. So where we are today is in large part due to the impacts from the CZU fire on our community, where in addition to the 911 homes that were lost during that fire, approximately 75 of those homes were along the Highway 236 corridor in and around Boulder Creek in areas that have historically high groundwater levels and challenging onsite treatment systems, which likely would require expensive enhanced treatment systems to meet current lamp standards. So as part of the board's direction in working with environmental health, there was a five year grace period identified for those property owners rebuilding, where if we could move a project, a Sewering project forward, not completion, but move it forward with a vote that it was gonna be moving forward successfully, those folks rebuilding would not be subject to enhanced treatment standards if their lot was requiring it and that they could wade out to the installation of that new sewer system. So that fire created this unique opportunity to re-explore the Boulder Creek Water Quality and Recovery Project and to address some longstanding issues and some near-term issues. So what this project brings to bear is what we have as four major pillars, the first being environmental protection. As we said that water treatment systems in the valley aged and unregulated have contributed to high nitrate concentrations, impaired water body statuses for the San Lorenzo Valley. This type of a project would hopefully improve water quality, surface water quality in the San Lorenzo Valley. It has the opportunity to provide recycled water that could also be used by the golf course. Currently the golf course is watering its nine holes that are operating as a golf course with potable water in a community where we don't have a straw anywhere else in the state for water. It's a big deal to have potable water being used on golf courses. Obviously in Paso Tiempo as an example, in the past we changed that to being recycled water from Scots Valley. The other piece, as I said, disaster recovery, trying to reduce those costs to re-build. Climate change, resilience is really the piece that I wanna highlight where this opportunity gives us another recycled water source in our county with Pure Water Soquel coming online in the next year or so. We need to continue to look at and explore opportunities to develop recycled water sources throughout the county. So we have that already in Watsonville. We have a recycled water plant in Scots Valley. This new one will be coming online in Soquel and this is another opportunity to provide recycled water from a myriad of opportunities and uses not the least of which is potentially recharge opportunities in the watershed as well as fire suppression storage. So if we have a large water tank of recycled water we could be using that for wildfire suppression. The other interesting thing that has come out of the fire is that Big Basin State Park, the largest and oldest, not largest, the oldest state park in the state is reorganized its entry. Its main headquarters now is just up the road in 236. So Boulder Creek becomes the gateway to that state park and the future hopefully return of the two million visitors annually. So the economic vibrancy of Boulder Creek would be tremendously improved by getting those businesses onto sewer systems rather than the hallway program that they're currently on. So what does this project look like? This is a map that has a number of color-coded communities that have been identified through the feasibility study. The pink, granted, t