Health Safety Education and Services - Regular Meeting

Welcome back to this weekly meeting of the Health and Safety Committee with Denver City Council. Coverage of the Health and Safety Committee starts now.

Good morning and welcome. My name is Darrell Watson. I'm honored to serve as the chair of the Health and Safety Committee. This is August 19th Health and Safety Committee meeting. I'm kind of stalling because we have guests that are arriving. So great. Welcome to Health and Safety Committee meeting. This is Darrell Watson. I'm honored to serve as the chair as well as the city council member representing all the defined District 9. We have one action item today is Denver Health and DDPHE amended contract with Denver Health to distribute sales tax revenue. And before we roll into that presentation, why don't we do introductions of city council members? We have Council Member Sandoval, it appears, is online. We'll start online first. Oh, not there yet. To my right, and then we'll come back to Councilmember Sandoval.

Thank you, Mr. Chair. Kevin Flynn, Southwest Denver's District 2.

Good morning. Diana Romero-Campbell, Southeast Denver District 4.

Good morning.

Paul Cashman, South Denver District 6.

Hey, everybody. Serena Gonzalez-Gutierrez, Councilmember at Large.

And I'll do one quick check to see if Councilmember was able to sign in. I don't want to put her on the spot. If she's not on, that's fine. Not in as yet. Nope. So let me turn it over to our friends from DDPHE and from Denver Health for you to introduce yourselves, and I'll turn you over for the presentation.

Good morning. I'm Elise Matotol with the Denver Department of Public Health and Environment. I am the Denver Health Sales Tax Administrator.

And I'm Donna Lin, the CEO of Denver Health.

Stephanie Siner, Government Community Relations for Denver Health.

Perfect. Okay, I will get us started. So we just did introductions. I'll talk a little bit about the background of this sales tax initiative and contract, a little bit about the timeline, the ballot issue, 2Q. You'll hear us sort of intermittently say 2Q versus Denver Health Sales Tax Fund. And we'll talk about some of the historical revenue. And then I'll give an overview of the contract, accountability within the contract, the admin funding to the city. And then we'll talk through the proposed changes so you know what is being amended. Here's a little bit of a busy slide about the background and timeline. So ballot issue 2Q was voter approved in November 2024. Council and the city got to work right away in January 2025 to approve it. In May 2025, Denver Health shared their spending plan with city council and DDPHE. And then in August 2025, they presented their mid-year spending plan update. I was hired in July 2025. It's sort of in between those two boxes. And then November 2025, Denver Health was asked to come back to present some more further detail. 2026, April, they presented their 2026 proposed spending plan and the annual report at Council. The annual report was published in May 2026. So you can see that we've had basically one full year of the full contract and reporting cycle. So we've learned a lot along the way, definitely adapted and tried to incorporate a lot of those adaptations into the contract. The original contract term was two years, so ending December 2026. The ballot issued to Q, I'm sure many of you voted on it, just pulled some important language from the legislative intent. As a safety net hospital, a disproportionate percentage of those served by Denver Health are individuals who are uninsured or underinsured. On average, Denver Health has absorbed approximately 100 million in each of the last two years. for uncompensated care being provided to Denver residents, and dedicated funding to apply to that gap is necessary to sustain the critically important work and services being provided by Denver Health. The ballot initiative authorized a sales and use tax, about 34 cents on $100 purchase to fund these five, we call them buckets, emergency and trauma care, primary medical care, mental health care, drug and alcohol use recovery, and pediatric care. I won't go into more detail because you'll have a presentation after this from Denver Health themselves. A little bit of background about the sales tax revenue. So the actuals for 2025 were about $65.7 million. This year is projected to be about $68.5 million. And then next year is projected to be about $72 million. So a little bit of an increase, but I wanted to flag that it's pretty normal for these new sales tax initiatives to go up and then level out. So I don't anticipate, I'm not a budget analyst, but I don't anticipate that they're going to continue to go $3 million every single year. Part of that is related to new audit revenue that was attributed to the fund. So we'll go into the details, but just wanted to show the revenue over time. So the contract overview, the scope of work recites many of the ordinance requirements and prescriptions. This will be a five-year contract. We added three additional years for the full five years of what's allowed. As you all know, the city collects the sales tax and then gives it to Denver Health, which is the spending agency. We distribute it monthly. There's no contract maximum because it's appropriated annually based on the sales tax revenue. The DDPHE is participating in the annual budget process. Denver Health sort of slides in under our budget participation. I will go through some of this more, but we also have the 1% city admin. So Denver Health submits a monthly distribution request, basically an invoice, that's 1 12th of the revenue and the revenue projection. And it's paid immediate term, so they're receiving that every single month predictably so that they can plan for their finances. This is a little bit of just bureaucracy, but any unspent funds will stay in the fund, and that's more on the city side, so it's not like general fund where it would go away at the end of the year. If anything were to happen, we couldn't distribute it in time or anything like that. It would remain within the tax fund. The annual reconciliation process is after the city's financials are completed, including any unspent 1% admin fee. So I know this is a busy slide. I spent a lot of time grappling with Microsoft Office trying to formulate this, but really wanted to show how we're thinking about contract accountability. So the first step is that Denver Health and the city provide an annual proposed spending plan addendum. That's the roadmap for the future year. That includes the categories, so the spending buckets, amounts anticipated within that and then associated metrics and then they come back for their mid-year update and spending plan to make sure that we're on track. There's not any material variances within that or if they want to update anything because of changes they have the ability to do that and present on that during the mid-year spending plan which you'll see after this presentation. That feeds into then the annual report. So the annual report sort of goes back to the proposed spending plan and says, did we do what we said we would do and propose? So that also includes the use of the monies from the tax plan, report on metrics, and then you all include your audited financial statements. So part of the contract is that Denver Health will come present no less than twice per year to council. And that's the proposed spending plan presentation and then the mid-year update. I just wanted to grab a screenshot of that spending plan addendum that Denver Health sends to DDPHE. So it has the amounts within each bucket, the budgeted visits, and then the key areas of focus that are more of the qualitative metrics. So the city administrative funds that I talked about are how the city is administering the fund, overseeing the agreement, ensuring accountability, and coordinating with DHHA. So the DDPHE executive director designates a liaison. That's me, the Denver Health sales tax administrator. The city also develops our own proposed annual spending plan that we're including with Denver Health so that we all are aware of how the city's planning to spend our 1%. We report on how that happened, basically on the same schedule. And then any unspent city administrative funds are distributed to Denver Health. So last year, I think it was about $500,000 of unspent funds that we just included during the annual reconciliation process. I wanted to talk through the actual proposed changes that we had grappled with. There are some things we were just cleaning up, but these are the more substantial things that we changed within this new amendment. So we clarified the metric reporting. We included some more details around patient volumes, patient demographics, quality metrics. That was all included in the first contract, but we added a little bit more around making sure that Denver Health has the ability to add in two to four metrics within these domains of volume, quality, and clinical impact, and then adding in some more detail around just baseline data, prior year equivalents, reporting cadence, how often are you all gathering that data, and what are the sources, and alternative methodologies so that DDPHE can verify that the data is actually accurate or true or verifiable. So that all was included in the metric reporting part of the contract. We also aligned some of the due dates. So after our first year, we realized that the annual report was due before Denver Health had approved their actual finances. So we adjusted that to reflect the actual Denver Health fiscal year. We also wanted to make it easier. Denver Health has talked about providing integrated care, and it's a little bit hard to separate out the mental health care and drug and alcohol use recovery, so we gave them the option to combine that reporting if desired. And we also added a proposed section, basically writing out, you saw the annual report last year, but this is the outline of what they produced for the annual report. So I wanted to give credit for all the work that they had done after this full year of reporting. This is the outline for the report. So there's a CEO summary, the background and methodology, overall payer mix, quantifying the uncompensated care that was provided, outlining the reporting methodology and allocation overview, financial accounting by clinical category impact, and then any additional metrics that we outlined in the previous section. That is all. Any questions?

Thank you so much, Elise and team. I know you didn't pull this together by yourself, so thanks to the team from DDPHE for pulling this forward. I want to recognize that Councilmember Sandoval and Councilmember Torres has joined the meeting. I know that Denver Health has a full report out in the briefing following this action item, but because you are here, I'm wondering if you wanted any make any quick comments on thoughts, insights from the DDPHE presentation before we open it up for questions from council members.

Do you want to go to your questions about the Lisa's presentation and then I do mine and then we'll have like a vote on this action item.

So we have a regular process, but I thought since you are at the table and very much involved in this process, we have any initial thoughts that you want to add to the room for this action item.

Yeah, I think one thing that's important, and Elise covered the fact that we've changed some of the metrics. And the purpose of that is not just to measure how the money is spent, but over a period of time, what's the impact of the money that is being spent. So that is not something you can do in the first or even second year of the agreement. But certainly what we call outcomes data, we can say this is how much we're spending, this is how many visits we're doing. in the longer run what we'd like to be able to say is and here's the impact that it had on the people in the city that we're serving but that is not a you know particularly in the behavioral health area you can't say we spent some money in 25 and we cured people by 2026. so that will that is part of the spirit of our agreement that will continue to refine some of those metrics Otherwise, I think I'm fine. You can go to your questions and then I'm happy to talk about the details when you're finished.

Perfect. All right. So let me open up the queue to council members. Any council members with questions for Elise and DDPH 18? The queue is open. Council Member Torres?

Thank you. Thank you all so much. Um, we can go to the revenue forecast. Um, we went to voters with the 65.7 estimate. Okay. And we ended up at, uh. Anticipating a 68.5 in, uh. But it's the 25 number that we don't have to go back to voters to keep that additional funding, do we?

No, it's appropriated annually. And there was an estimate, I think, in the initial ballot initiative, but there was not a hard number that we could max out at.

Is that we had to do that with climate and. John Griffin, do you remember if we exceeded the 1st years estimated revenue, we had to go back to voters to keep the. Excess that was actually received in that 1st year. Can we just double check if this way to do it for climate and homeless. services. I think something like that. But I can't remember if it was a 25 projection number or a 26 projection number.

Yeah. And I think it had to, it was the first year and we could not exceed the 70 million. 70. Yeah. So we got from 65 to 70. If we would have gotten 71 that first year, then we would have had to go back after that first year to reallocate that additional funds. But now that we've hit the first year, we can And it was under the 70 that was in the ballot. Yeah, we hit the 68.5. Perfect.

Okay, I think that, oh, Laurie's coming up. And we see attorneys marching to the mic.

Sure, that's correct. So, Laurie Simonson, Legislative Counsel. When you pass the measure, you set a maximum amount for, in the ballot language, you set a maximum amount for the first year. So, if you exceed that, by TABOR, you have to give that money back to the voters. So if afterwards, in subsequent years, you go over that amount, it's not an issue because what you pass is in the ballot language. You can't really change that without going back to the voters. Any subsequent year, if you had ballot language that said for the first two years, we're not going to exceed X amount, then you would be tied to that.

Okay. And Stephanie, you're saying we had said it would be 70 million in the ballot. Yeah.

So we initially said 65 at a maximum of 70. Okay. And so then once we were a little concerned because it was 68.5, we're like, whoa, it's getting a little closer. But since we didn't hit that 70, we were fine to do the... Okay, super helpful. Thank you.

I think that we can confirm that as well. Okay.

Make sure to talk to. 72Million is based off what kind of analysis for 27?

That would be a budget management office question.

They're predicting a. That's 5%. Yeah, that's a big increase.

It's a big increase. I do think that, so there's a little note that says that part of it is because of the audited revenue from end-of-year auditing to the fund. I can talk to Budget Management Office, but my understanding is that this is the unofficial projection, so don't want to hold too much weight for it, but we can confirm where the analysis comes from.

Okay. That'd be great. Just want to make sure what I'm hearing on one side of DOF is matching what I'm seeing here, which is not matching. They're telling us flat as opposed to.

I will say my understanding is that sales tax revenue, because it comes from a specific section, it doesn't necessarily reflect general funds. So general fund might be flat, but because the sales and use tax that this is levied against, it might be different. That's similar with caring for Denver. We've noticed that too, that sometimes the general fund does not match the sales tax.

Okay, super helpful as we're going into budget season. And then I have the IGA up, but I'm just assuming that the changes from the existing one is just the duration. Were there other major areas that were updated in the IGA?

Yeah. My slide about proposed changes. So we cleaned up some legalese language, like outdated language or things like that. These were the most substantial changes to metric reporting, aligning some of the due dates for when the reporting would be and clarifying that they could report two of the buckets together if desired.

Perfect. Thank you for covering that again. Okay. Thank you so much. Thanks, Mr. Chair.

And thank you so much, Council Member Torres. And we're going to ask for BMO, if this moves to the floor, to be available to answer those questions as well, Elise. So thanks for checking with them, but we'll circle back with them as well. In the queue, we have Council Member Flynn, Council Member Sandoval, and then Council President Romero-Campbell.

Thank you, Mr. Chair. That's going to be my question about the 5% projected increase. I wonder, could you come work for us?

It's not my projection.

All right. Because even our sales tax projection is flat as well, not just the general fund. I know we had a good quarter two report, 6.8% in sales tax, I believe. But that's so volatile. and seasonal dependent.

And Councilman, if I may, and you'll hear in my presentation, even as it increases, it doesn't cover the full amount of the uncompensated care that we provide in Denver. So you heard Elise say it's about 100 million. So even if we get to 72, we still have a shortfall of 28 million in uncompensated care we're absorbing. And I'll talk more about that and why that's actually going to start going up in 2027 due to things that happened in Washington.

Thanks, Don. That's not my issue. If you fall short, if it exceeds 72, that's not my question. It's why DOF is so optimistic for 2Q, but not for general fund. We'll find out next month. Yeah, we will. And thank you for our new procedure of having the documents available prior. Does this replace Existing agreement is this this isn't an addendum to it.

This is the new whole agreement because it's like five pages Yeah, it's a I've noticed working on these sort of special child's of the caring for Denver contract and the Denver health contract instead of line item editing the contract because we're not necessarily using the CEOs and boilerplate contract, it's a totally different one. We had to edit line by line within a Word document, so it does totally replace the other one, which I know makes it hard to see the line by line edits, and I'm happy to provide some more analysis if that would be helpful.

Okay, because it's hard to find what are the differences, so I'd have to compare this with the existing one, then do it side by side. It'd be helpful if you could provide that, so that I don't have to do that work. Anything I can take off my plate and put on someone else's, I take advantage of that. And Elise, do you know, and maybe you can't know this or don't know this, but you said there were audit exceptions or audit components to that $72 million projection from DOF. Do you know what those are, or should we ask that of finance?

It would be way above my pay grade, but I will write it down and make sure that our- Ask them to get that to us.

Yeah, I will. Thank you so much. Council member Flynn council member and council.

Thank you. Thanks for all the great work. This is a really important contract for us at the city. So, I'm looking at the city administrative funds. Last year were any unspent funds given provided back to Denver health because according to your slide 10, any unspent city administrative funds at the end of each year will be distributed back. Were there any distributed back last year?

I apologize for not putting it on the slide. I said it verbally in my voiceover, but we provided about $500,000 additional. So during the reconciliation process, Denver Health gave us an invoice to pay for the difference in the sales tax revenue, and then we added on the unspent $500,000. It was about $524,000, I think.

Okay, and then for Donna, thanks for being here. We're aligning our dates for the annual report to. Accommodate Denver house fiscal year. I don't see it on the side and I didn't catch it. It might be because I was on zoom or if it wasn't said, what is Denver house fiscal year?

Our fiscal year, Councilwoman, is January 1 to December 31, so the same as the city. But we close out our book. It takes months, as you probably work with your own financial auditor. Our financial auditor takes generally until the end of March into early April, reports to our board. So hence, that longer time frame is important to just be precise about how we're spending the money.

And then with the new date of May 1st, would that mean you come to city council committee and you report out on that annual report?

Yeah, so it's it's the annual report and the new spending plan for the following year.

Okay.

even though we submit our spending plan.

You'll already have been in quarter two of the spending plan, right?

Right, this submitted to DDPHE at the beginning of the year in January, but we won't present to council on the spending plan and the annual report until May when we can bring both of those together.

And we talked briefly, Stephanie and I talked briefly about this. The presentation to council will still cover all of the information, but the written annual report will now be due May 1st to make sure everything is finalized. But it's not like things would change substantially from a presentation to the written. It just gives their team time to make it very pretty.

OK. I think that's it. Thank you, Mr. Chair. Thank you.

Thank you, Council Member Sandoval, and then Council President Romero.

Thank you, Mr. Chair, and thank you for the presentation. Really good work. I have a question a little bit around the annual report, but I think this is also where you were talking about the metrics and being able to align those. Can you expand a little bit? I know you touched on it, but just maybe expand a little bit more on the metrics that... will be reported back and will that come in the annual report that we were discussing?

Yes. So thank you Councilwoman, Mayor Campbell. We provide much like we do on the operating agreement. The City Council and the Mayor get a bound annual report that gets into every component, you know, how many people we see, where they're coming from, And so we gave that, so that was delivered on May 1st to the council. So we would continue that same cycle. And as I said, really think hard about how do we think about the outcomes of the money, because I know that certainly is a concern from the council and certainly from the taxpayers. This wasn't just go spend some money. And I'm going to get into some of that, a little bit of that in my presentation.

Great. So maybe my question's premature and you're going to answer it in the next part of the session. Thank you, Mr. Chair. I look forward to hearing it.

Thank you so much, Council President. I just have one question. Elise, are you the sales tax administrator? I just want to make sure that's entitled. Oh, there's a smile. I thought you said that, but I wanted to verify because I know that we were identifying who that liaison was and so it's good to know that that's you. That's my question looking around the room for the last call. Any additional questions from anyone else? Seeing none, this is an action item. We'll need a...

Were you going to present more? That's next, I got you.

Wait, hold on.

No, no, I thought she was going to present more, but I see what you're saying for the action item.

Out of order, President.

There is a motion on the floor. I'm not chair of the committee.

All right. There was a motion. Who was second? Cashman and then Torres. Second. Is there a need for any further discussion? Can we do a thumbs up? In Sandoval, we're solid? All right, we look forward to seeing you all on the floor. We're going to do a little musical cheers because we now have a briefing from our friends at Denver Health about the sales staff spending update. Thank you so much, Elise. Now that I know your new title. Did you need a cab to get there? And whenever you're ready, Stephanie, you can drive it.

Thank you. Well, thanks for the opportunity to be here. And Mr. Chair, I will go through the slides and avoid any redundancy because you've heard a little bit from Elise. Just to take you back, though, I think it's important. Denver Health spends about $140 million a year, or absorbs $140 million a year in what we call uncompensated care. So those are people that are purely uninsured that come to Denver Health, and that's part of our mission to provide care regardless of people's ability to pay. And secondly, Medicaid, the Medicaid program and 47% of our patients are on Medicaid and we do not receive adequate reimbursement from the federal government for that. So it's a combination of those two things. And I'll break out in a slide in a minute what comes from the city. As you know, we've had a lot of conversations about uncompensated care that comes from outside of the city and what the obligation should be. So as I came into this role four years ago, I looked at the finances of Denver Health and they were literally a roller coaster. There were a few years where the finances were okay. Actually during COVID, ironically, federal government supplied so much money and we made some reductions in staff because we weren't sure what the volumes were going to be. So we actually made money in 2020 and a little bit in 2021 and then cratered after that. And so as any organization needs to have a little bit of a surplus of their revenues over their expenses to be able to invest it struck me that we had a lot of challenges moving forward. And so we engaged in a process that a number of former elected officials and other community leaders participated in, and we worked with them, and that resulted in a recommendation to go to the voters for some additional funding to cover our uncompensated care. And as you heard Elise say, that's what we affectionately call 2Q. It is a sales tax. We polled whether it should be a property tax or sales tax and the voters came back and said sales tax, which I have my own philosophical problems with because it's regressive, but it is what the voters agreed to. And we derive a substantial amount of sales tax from people who are non Denver residents. it's actually okay on some level. So the sales tax, in addition to just being, as you've heard, 3.4 cents on the $10 purchase or $34 on a $100 purchase, was designated to cover certain areas. This just wasn't open-ended, please send us some money. And so these are the five areas that We selected again partly based on where we were seeing the most uncompensated care and partly because these things are really essential to providing care to people, hopefully in their communities and before they get very sick. So the next slide shows you that uncompensated care. In addition to the roller coaster, this has been almost a straight hockey stick, as they say, with a little bit of a dip last year. But you can see that the problem of uncompensated care has almost tripled since just 2020. And some of it came from the county. Just to be clear, the blue bar are Denver residents. So as you heard Elise say, it's about $100 million in uncompensated care attributable to Denver residents. And then the orange bar is outside of the city and county of Denver. Why does that happen? It happens because we're a level one trauma center. It happens because people do travel into the city and county of Denver to go to a Broncos game, hopefully to shop and spend sales tax money, as I said. And in some cases, we know that these are patients who used to live in Denver, can't afford to live in Denver anymore, moved slightly outside of Denver into Adams County, Arapahoe County, but have had a long affiliation with Denver Health and the services that we provide. I'm going to talk about the future because 2027 is a really important year for Denver Health and for the city. If you can go to the next slide. As you know, we were a city agency and had a healthy divorce back in 1997 where we became a state authority. The city provides what is known as an MI payment or medically indigent payment. That is that orange bar that has been completely flat for 29 years, which is unfortunate because our costs go up. And that's what this slide shows you. Several things have happened. We see more people. We're seeing more complex patients, particularly those who are uninsured or underinsured. And healthcare expenses, unfortunately, go up at a much higher rate than general inflation. So just as an example, I can tell you that today, while not about Denver Health, employers, and I don't know what's happening with the city, are generally seeing their healthcare costs for next year go up by 10% to 15%. Some of that's the aging of the population, some of it's new technology, the cost of drugs, but it's getting more and more expensive to take care of patients. Our budget for 2026 is $1.7 billion. We are about the same size as the city and county of Denver in totality. 2Q came in, as you heard, in January of 2025. And so the city MI payment of almost $31 million and the $65 million that we get is getting close to the $100 million, but the $100 million is just going to keep growing, as you'll see later on. You can go to the next slide. Okay, so what are we facing? 25 and 26 were years of some stability, but because of what's called H.R. 1, or the One Big Beautiful Bill, we have huge changes on the horizon. Beginning October 1st, asylum seekers and many other people who are here legally will lose their insurance. We know January 1st of 2027, there are new Medicaid requirements that impose work requirements of 80 hours a month that require Medicaid patients to recertify twice a year. Many of them are challenged in terms of transportation and other demands in their lives. And we will see some other programs at the state level, especially cover all Coloradans, that will decrease. So what does this mean? It means that we know we are gonna see more uncompensated care in 2027. The good news is Denver Health does enroll patients in Medicaid. You're familiar probably with the old Robert Speer building landmarked on Speer, just north of 6th Avenue. We have enrollment specialists there. We have enrollment specialists in all of our clinics. But we've estimated that over the next five years, we will lose about 20,000 patients. from Medicaid eligibility to becoming fully uninsured. And that doesn't include those that might come from other localities. But for your purposes, the Denver population, we're thinking by 2030-ish, we will lose about 20,000 members, despite the fact that we are adding more enrollment specialists to do some of this work. The other thing that's in H.R. 1 is that some of the supplemental payments that we get, the federal government will be taking away again over a four to five year period. So what does that mean? With people being uninsured, they're gonna delay care. They're gonna come to the emergency room. That's the wrong place to get care for two reasons. They're sicker and it's much more expensive to deliver care in an emergency room than it is in one of our community clinics like the Gibson Center that you saw last week when we dedicated the mural. And that is really concerning to us. And as I said, healthcare expenses are growing at double digit numbers. Go to the next slide. Okay, so what are we trying to do? We want to achieve financial stability for Denver Health, for our employees, for the benefit of the city, and to be able to invest in some areas where we know we need to invest. At some point, we'll be back here to talk to you about some of our infrastructure and our need for additional support to replace our hospital, which was built in 1970. And we're constantly fixing HVAC systems, broken elevators, et cetera. But for now, the short-term goal for 2026 is to make sure that we're delivering good care to our patients. You can go to the next slide. Okay, so I'm going to go into each of the areas where we, as we said to the voters, that we would utilize 2Q money. And I want to be clear, although I'm going to talk a little bit about enhancements, this was intended to cover our uncompensated care. So the $100 million that we have in uncompensated care, it falls into these areas. But at the same time, I thought it was really important to invest in some new services, and I'll detail that as we go through the presentation. So the biggest individual category is emergency medicine. I think you all know we have a level one trauma center. It's huge activity. We have 100 rooms in our emergency department, both for children, adults, and for psychiatric patients. You can go to the next slide. So we spend about 170, just a little under 170 million for our ED services. You can see from the orange bar where we get money for that. We get that from Medicare, Medicaid, some insurance companies. But our shortfall in terms of that 170 million is about 37 million dollars. So we have allocated to support those services about $34 million from 2Q, and we still have a significant portion of uncompensated care that we have to cover. You can go to the next slide. So how do we spend that money? Just to give you a flavor, as I said, we have 100 rooms in the ED. We see about 120,000 visits, excuse me, in 2026 is our estimate and we're more than halfway there for this year. We've invested in a few things, partly to make sure that we're expediting and providing the kind of care that we need. And one of the things we do need is, I guess I would call them concierge. That's probably the inappropriate word. We call them patient engagement specialists who are just trying to make sure people get the services that they need and their care is expedited. We also, you may be aware of our Sexual Assault Nurse Examiner Program. We have had this for 20 years now. It is located in a nondescript building on Platte Valley Road and it is about to move once the 2Q, I'm sorry, Vibrant Denver money is spent to create a place where young people who we suspect have been abused by their family members or others are given a forensic exam. And so we have seen that increasing and we are adding just about a little under half a million dollars to continue to meet the demand in that space.

You can go to the next slide.

Okay, so the second area is primary care. Again, that's where we prefer people get their care, not in the emergency room. And we spend about $100 million. We have 30 locations to provide primary care from Sloan's Lake to Lowry and up into Montbello and now into... Councilman Cashman and Councilwoman Romero-Campbell's districts. We have a new clinic that opened in July on Evans and Monaco for primary care and will be open for specialty care and other services in December. So we spend about 82 million dollars in our, we receive it, sorry, 82 million dollars in revenue from again those sources, Medicare, Medicaid, commercial insurance, but we still have a shortfall and we spend of 2Q money about 24 million. You can go to the next slide and I'll tell you some of the things that we've done in primary care. The Southeast Medical Center, while we could not use this money for capital, the 2Q money is really expense, so that is helping us start off with some of the operational expenses, and we've also hired a number of additional WIC educators. As you know, there's huge demand for women, infants, and children's programs, and we have those in most of our clinics, and we have added seven new. Again, this is Not the sole purpose of 2Q, but there are needs that I and my team have looked at and said we've really got to continue to do some of this work. Go to the next slide. So the third area is pediatrics. We spend about 20, almost 20 million dollars in pediatrics. And there's a small shortfall in terms of our uncompensated care. You can go to the next slide, Stephanie, and we'll share with you some of the things that we're doing. We operate a neonatal intensive care unit in the main hospital, and we have added some staff to continue to improve those services. Children's Hospital and Denver Health and Rocky Mountain Children's Hospital are really the only facilities providing this kind of care in the metro area. And, of course, in Denver, it is just us and Rocky Mountain Children. So we've added a small number of additional services in that area, but mostly it is going to cover the uncompensated care that we have. And then mental health, fourth area, a huge issue for us. You may not be aware. We see 280,000 patients a year. 88,000 of them have a mental health or substance use issue, so a third of our patients. We spend about $100 million in this space. And as you can imagine, there is a lot of this population we're gonna have uncompensated care for. They're not holding a job. If they're holding a job, it's very complex. And so we have close to $20 million of uncompensated care out of the care that we provide in this space. We've taken some of the 2Q money to help us cover that shortfall. And if you go to the next slide, we can share with you some of the other work that we have done, and I know a number of you have been to our IMAP, which is our Integrated Medical and Psychiatric Care Unit, which we had a ribbon cutting, thanks to several of you who handled the scissors, and we have 12 beds now. Why was that necessary? Believe it or not, when you get admitted, and perhaps for a psychotic episode, but you happen to also have diabetes, we would treat you for your psychiatric care, and then discharge you, readmit you for the medical care that you needed. And so this unit allows us to have staff who are both behavioral health specialists as well as traditional medical specialists. And we are really proud of the fact it's innovative and we have 12 beds. I was literally just there yesterday with the state's behavioral health commissioner. We also have had a number of challenges as you can imagine that are generated by patients. Patients who are angry, family members who are angry, who threaten our staff, who verbally assault them and also sometimes physically assault them. So we squeezed a little bit of money, excuse me for this.

Tell them I said hi. Monica Duran.

This helps us with, if any of you watch The Pit, it's my favorite film. It's real life and this is some of what we've taken, a little bit of the 2Q money that was not devoted to uncompensated care. It's good for our employees, obviously, to make sure that they stay with us and are not overwhelmed by some of the conditions in our hospital and our clinics. You can go to the last slide. I think we are at the last slide, or the last area, which is our alcohol and substance use. We spend about 14 million in this, so separate. the behavioral health side, although, as you can imagine, many people have both conditions, behavioral health and substance use. We have about 3 million in uncompensated, I'm sorry, 5 million in uncompensated care. Let me go to the next slide, Stephanie. This gives you a sense of the scope. We have about 65,000 visits that are alcohol and substance use related. From an outpatient basis in particular, again, we'd prefer to be taking care of people in the clinics versus hospitalizing them in our Pavilion A. And one of the things that we are doing is we have a methadone clinic. We call it Pavilion K. I took a walk when I first got here, and it reminded me of when I flew over the cuckoo's nest. And the conditions were unsafe for our employees as well as our patients. And I think it said something about how we knew people. So we have done some improvements in the environment of care, adding some staff. Just because somebody is on methadone doesn't mean that they're less of a person than somebody who needs their broken arm fixed. So we've done some work in Pavilion K, and it'll be done by the end of December. And I'd love to invite some of you. It's not as formal a ribbon cutting, but I'm really proud of the work that we're doing there. We also have a methadone van that you may be familiar with that serves our Westside Clinic as well as the Bernard Gibson Clinic. I think Stephanie you can go.

That's it. I just want to make one clarification. So because this is a mid-year spending plan, the graph shows what we've spent up to date. So we've only spent, we've spent $13 million and I think the one thing to call out is that if you look at the uncompensated care, the purple is the 2Q spend and the green is where we already are. Even though we haven't received the full 2Q, we've already allocated the full amount for those particular buckets for each of the sections. And we're anticipating this will be doubled by the end of the year. So just want to make sure that that's what... And then I think, Elise, you have a... I can do yours. I can help you.

Just a reminder that the city also provides a proposed spending plan and mid-year update on our 1% admin fee. So we gave the presentation with Denver Health earlier with the proposed spend and just wanted to provide an update similarly that we're on track with all the personnel. We don't anticipate that it would go down. I will say part of the reason that we gave $500,000 back last year is because I got hired in July and we didn't really ramp up until probably fourth quarter last year. So we will be on track for the personnel for services and supplies. I don't anticipate that we will spend all of the money that we had proposed, but again, we have the ability to spend it and we're always anticipating that we will be judicious with these dollars and we'll give back what we can. So we're under with all of those. Karen did tell me recently, you can buy a new, it's like, I have my, in front of the computer. Keyboard. Keyboard. She was like, you can get a new one. We have fee for that. I was like, oh yeah, right. But we have not been spending for things like that because we haven't needed to. I budgeted a little bit for conferences for training, professional development, and then we have a subcontractor, Third Horizon, that really has been instrumental in understanding what these funds are for, and making sure that we are asking the right questions, and not asking questions that are not the right questions, and not pushing in areas that don't make sense. So we'll also be under with our subcontractor as well, but just wanted to point out that that's a big piece of our services and supplies represent. Move to the next slide. Yeah, and I had just voiced over those things. But part of this also, the original projection was about $67 million, but it's been updated to $68 million. So our 1% would have been about $684,000, and we probably will give back about $250,000. I'm not a betting woman, but I imagine it will be close to that. That's it.

Thank you. All right. Well, thank you so much. Thank you. Thank you, Stephanie. Thank you, Elise. We do have a few folks in the queue. And so if folks want to jump in the queue, please let me know. Council Member Flynn first and then Pro Tem Gonzalez-Gutierrez.

uh thank you mr chair i think i am currently in your uncompensated care uh category yes dr federico met me in the emergency room when i tripped over a misplaced construction sign outside the city and county building broke my nose three stitches in my lip and your services were excellent thank you your paramedics were there very quickly in the web building and uh And the follow-up was great with the ENT. And as you can see, I looked nothing like I looked when I came in. When Dr. Federico said, hey, welcome. But you will be compensated. My insurer says you're out of network, but apparently it's a worker's comp claim. So you should be fully compensated.

We will make sure we do not send you a delinquency note.

Well, at my age, you know, 34, that was my first time ever in an ambulance and in a hospital for any procedure. So I found myself lucky and fortunate that I went to our best trauma care center in the metro area. That leads me to my question on slide eight. In the ordinance that voters passed, it spells out the categories of spending. But there is no percentages applied to each, so you are free to allocate as you will. And I'm curious if you could explain a little more how you distribute the allocation, the 67.7 this year. How do you determine that this amount goes to emergency care, this amount to primary care? How is that calculation made? And does that change from year to year, or do you intend to use a set formula going forward?

It's really based on the uncompensated care that we get. And so it will change from year to year by small amounts. I am worried that the emergency medicine bucket will grow more because of HR1. But that's where the uncompensated care is coming from.

And we've been really lucky that we haven't had to move, but the ordinance allows, that's why we have a mid-year check-in. If in 27 or 28 we see our emergency room triple, we do have the ability to come back to council and say, our CEO says we can no longer put money towards pediatrics and mental health. It needs to all go into emergency services. So that is really the intent of this briefing, is that if there is anything drastic, that we do come back and report to you where we have to make those shifts.

Okay. This might be an angel's dancing on the head of a pin question, but are there occasions where you could put it in one category or another? If a young patient comes into emergency, is that pediatric care or is that emergency care? That's emergency. That is emergency care. Okay. All right. I'm very glad that you're flexible to be able to change that and that we didn't lock you in to having to spend it on certain areas. Thank you.

That's all. Thank you, Council Member Flynn. Pro Tem, Gonzales Gutierrez.

Thank you, Mr. Chair. I'm always learning new sayings from you. I have no idea what that means. I have to look that one up. What was it? Angels dancing on the head of a pig.

How many angels can dance on the head of a pig? Yeah, that's a new one.

I don't know if anybody caught that.

It's a Catholic school question.

But always learning something new. Thank you all for the presentations. And I didn't have a whole lot of questions for the former piece, but I know I had some questions for Denver Health, so I was waiting for you all to give you all an opportunity to present. Can you remind us how you are calculating the uncompensated care? Like, how do you get that estimate?

How are you arriving at that number? And I brought with me, because we always have a lifeline, Jeremy Springston, who's our director of reimbursement. It's easy to calculate the uninsured. It's like dollar for dollar. So we have the expenses that we have that are devoted to, you come into the, let's use Councilman Flynn, even though he's not uninsured, he comes into the ED, we had doctors, we had nurses, we had the ambulance transport, we would add all that up, that becomes the uninsured component. Medicaid is a little different, and I'll ask Jeremy if he would come up and talk about Medicaid.

And sir, if you don't mind introducing yourself and

Good morning, Jeremy Spragson, Director of Reimbursement at Denver Health. And so the way uncompensated care works for, say, a Medicaid patient is we identify how much it costs to provide that service, including the doctors, the nurses, including an allocation of overhead costs. And then we identify, well, how much did we receive in reimbursement for that service? So Medicaid would pay us. Even though it doesn't cover the cost, it might cover a majority of the cost. What the uncompensated care ends up being is what we identified as the cost of providing that service compared to what we got paid, and then what's left over is the uncompensated care.

And as a rule of thumb, if you read policy papers, Medicaid tends to cover about 80% of the cost of care, and then we're stuck with the 20%, which is why an institution like Denver Health, there is no other institution that has the percentage of Medicaid patients that we do. It's 47%. Children's hospitals, close. But none of the other... Rose, UC Health, etc. So that's why there's a differential burden on us because we have a lot of 80 cents on the dollar and they have a lot of dollars on the dollar or even more than a dollar on the dollar because they have more patients like us who have traditional Blue Cross or Kaiser, etc.

So if the client, if the patient has Medicaid, you're saying about 80% is covered, 20%, then you have folks who are uninsured, like you said, that you have that. So I'm curious if, If it also includes like the supplemental payments that you get from the city, from the state and federal government, I know the federal government is like, not probably in the best place, but, you know, city and state, there are some some funds that come in. Is that incorporated in the 80?

Yes, it is. So if we didn't include, so we get a straight payment, let's say burn appendectomy, we get from Medicaid. That would be probably closer to 60 cents on the dollar. And then there are things called dish payment. You know health care. I don't know all of it. So there's disproportionate share payments. There's state directed pay. So there's a layer of things that we can get. What the H.R. 1 does, though, is it ratchets those down. It doesn't eliminate them, but it does ratchet them down. And it ratchets them down no matter what state you live in or zip code you live in. So it's going to hit the entire country beginning in 2028.

One other thing, just pulling from our former colleague, Councilwoman Parity, she, I think, had received like a workbook for all the uncompensated care calculations for, and this was during last year's budget hearings, and as we're getting ready to embark on that again, are we able to get access to those again for the whole body? Absolutely. For 2026? Absolutely. Okay, cool. And then my last couple questions are, I'm curious because we see the uncompensated care starting to like the significant increase in 2020. We know like the pandemic and all of those things. And then, you know, we see the increase and then we see the decrease. Can you kind of explain what the reasoning that you're seeing there? Because I know there were things put in place, right, that we were paying, that more people were covered, right, prior to now.

And so just curious, yeah, how that... So a couple things led to the increase. One was the new wave of migrants. So that's not exclusively the issue in terms of the increase from 22... 23 and 24. The other is, I mean, I'm gonna give ourselves a round of applause. We did a lot more work to try to make sure that uninsured patients, where we get zero, became Medicaid patients. We actually have 90 people that work at Denver Health that do that work. So we were spending a lot of time to make sure that people could complete the paperwork, that they weren't afraid to do that work. So we saw an increase in the number of people who are on Medicaid and a little decrease in the uninsured. So it was better to get the 80 cents and not get the zero. Right. So that led to a little decrease in the uncompensated. Okay.

I think my last question is around each slide that depicts the 2Q funding gaps. I was trying to look... to see how you're allocating the operating agreement, so the medically indigent payment, or is it allocated to other service areas? So like, do you show the MI payment? Is it reflected in any of these numbers?

No, the MI is not. No, this is just 2Q, specific. This is just 2Q.

Okay, so it's not incorporating the MI. Okay. Okay. All right. Thank you so much. Thank you, Mr. Chair.

Thank you, Pro Tem, and Council President Romero-Campbell.

Thank you, Mr.

Chair. Yeah, this was the part of the presentation I just really wanted to see with some of the metrics. I'm just trying to see if I heard this correctly. So with HR 1 and the changes in qualifying and staying on for Medicaid, that impact you are expecting a decrease in the number and what was the number of?

So right now. Individuals and then. Right sure let me start at the high level. So we have 280,000 patients that we see 47% but let's just make it 50 it's easier. 140,000 of them are on Medicaid. We think that over the next four to five years that we will lose 20,000 of them. They will become uninsured. The one thing I also didn't mention is you're probably all aware that if you're not eligible for Medicaid, You can still go on something called Connect for Health Colorado. It's called the exchange. And it's national. You either have a state exchange plan or you have a federal exchange plan. In Colorado, we decided to do our own. The premiums for those, an example might be I drive an Uber. I make too much money to qualify for Medicaid, but my employer doesn't offer insurance. So I go buy it on the exchange. Well, the rates on the exchange for this year went up 13%. They're projected to go up 17%. So imagine you're that person. Maybe you're young, you're healthy, and you say, I'm dropping my insurance. then something happens and then you go to the emergency room and then you're a hundred percent we're getting zero again for that person and we can try to qualify them for Medicaid but there was a reason why they were on the exchange they were above a hundred and thirty percent of federal poverty so we have two things going on at the same time the Medicaid is the Medicaid Barriers, I'll call them, twice a year, recertifying work requirements are more significant than the exchange, but the exchange rates will lead to more people dropping insurance. And nationally, I think it's somewhere around 10% of people this year have said, I can't afford it. I'm just going to gamble.

Thank you for that, I think. Again, the complexity of it and the chain reaction of each of all of the different components have a huge impact. There was the slide where you had about pediatrics, and my... My wondering is pediatrics, but also the maternal and child health care that is provided at the hospital. Are you seeing an increase? I know at one point we'd had a conversation about the number of births per year. I think it's the largest in, you have more births at Denver Health? Any other hospital. Any other hospital. Are you continuing to see that increase, or is that maintaining? the link between the maternal and child health part and the pediatric component.

So we see we have over the last couple of years we've seen about 4,200 to 4,400 births a year at Denver Health. So we are a third of all the births in the city and county of Denver. So Rose, St. Joe's, you know, other places. We are the single biggest of that total population. The state reports and I don't know if the city reports on those or they just derive it from birth certificates. So that's a separate category. The maternal and child falls into more traditional inpatient care. But yes, once the child is born, we want to keep seeing them and they would fall into the bucket of pediatrics, which is really outpatient pediatric care, so routine office visits, immunizations, etc. We don't capture all of them, you know, some of them go somewhere else for their outpatient care, but we do try to make sure that one of the first things that we do when somebody delivers a baby is see a pediatrician, so they start that regular cycle.

Thank you for that work. It might be too early to predict, but have you seen a trend up or down?

So it's flattened. It's flattened. We don't know all the reasons why it's flattening, but it's still at a rate. Steve, do you remember? I mean, or Becky. Like five years ago, we were well in the mid-3000s, and now we've seen this spike.

Yeah.

Thank you, Mr. Chair. Madam President, it's complicated. I don't have a short answer for you. We definitely were impacted by new populations that came into Denver that definitely impacted some of the births we are seeing. That, of course, has flattened out. A lot of demographers have projected a declination in birth rates around the country. We're not seeing that in our data in terms of deliveries in Denver, and that's the part I think Donna's referring to that I can't quite explain why. We can say that it went up, now it's gone down a little bit, and now it's flattening out. So whether our demographics are different, whether our behaviors are different, I don't know the answer to that. I can begin to postulate there are a lot of different policy factors at play here, including declining access to birth control and family planning. That's gonna have a negative impact when we're talking about the birth rate if we're looking at a potential declination. So it's complex, interwoven, a lot of multi-factors there. And so we're constantly looking at it, not just from a staffing and cost standpoint, but also from a patient care standpoint and how we provide access to all the services.

I appreciate the texture that you just provided around that. I just, I think that's just something for us all to just keep our eye on as we move forward. Because I think that gives us a very good indicator of what is happening around and especially with the children and a broader context of. Where are they? Where are they? How are we caring for them and continuing their care?

I can assure you, as a practicing pediatrician at Mount Bello, we're plenty busy in the far northeast, and that doesn't seem to be changing.

Thank you. Thank you again for the presentation. Thank you, Mr. Chair.

Thank you, Council President. Pro Tem, Ms. Osketer.

Yes, sorry. I got back in because there was one other question that I had because I know I've had this conversation with you in one-on-one briefings that I've had as well as with DDPHE. And this is around the metrics and how those are related to the spending plan. And specifically... When we're looking at those key focus areas that you have on each of those slide breakdowns, um, are there cause I know Donna, you, you mentioned, you know, this is still kind of a ramp up phase. And I think it would be incredibly helpful, right? For us to be able to go back to the taxpayers and tell them, like, this is how your money is being used and it's going to good purpose. And we know it is right? Like. We know this is good, good, all good things, but just wondering if there will be a tie of metrics or at least targets provided for those key focus areas. So if you go, you know, for instance, you know, we were just talking about pediatrics, for instance, you have, you know, key areas of focus or pediatric visits, inpatient services, preventive and developmental care. Curious if the goal is going forward to tie metrics to those particular focus areas.

Yes, thank you for the question. It is. It's a long, you know, it's a longitudinal problem. So, for example, if we are able to immunize more children, you should be preventing, let's just make for argument's sake, since there's a lot of debate about immunizations nationally, we should be preventing the occurrence of measles, mumps, rubella, and other childhood diseases. So, yes, and it'll take a little bit of time. Some of the substance use ones, they're gonna be more challenging than following immunization or other sort of well-child and well visits, but that is our goal.

And to the point that the spending plan could change, if we go in the first year and say we're going to decrease by 30% in January in pediatrics, and then in the midst of the year, we have a huge Medicaid drop, and we have to reallocate those dollars. So I think what I want to... Be clear, those metrics you're probably going to see at the end of the year, knowing where we were able to utilize those funds to maximize what needs to be cared for, right? So, we had some of that in our end of year report where we were like, we decreased wait time by 60% because we used 2Q funding, right? So, I think setting those up at the front of the year are going to be a little bit tougher, but I do think as we're analyzing the spending, then we'll be able to give you those metrics at end of year. Steve, did you want to?

Yeah, Dr. Federico again. Councilwoman, I'll just call the committee's attention to the operating agreement annual report that we submit every year, which has a whole host of quality metrics that the organization tracks on an annual basis, and there are even more. I think the question on 2Q, what we're trying to target, is more what you're getting at, which is, In a specific time period, are we honing in on a subset? And I think that's where it might change year over year. I think Donna's example about vaccines is very timely, right? A lot of federal pressures on vaccine, a lot of reasons why we would want to focus on that more now than ever, a likelihood that our metrics are actually going to go down as a result of the misinformation that is coming out from that executive order that was just published. And so a mixed message perhaps to committee in the future that our data may go down even though we're focusing on that metric and trying to get the message out and make things more accessible and explain to you why and then how we improve from that point A to point B, right? So it's an iterative process and the following three years later it might be asthma and three years later it might be hypertension. All the while we are tracking all of those things. Again, some of it's already available to you in the annual report. What we didn't want to do is lock in and say the whole world of quality metrics and then it gets overwhelming and then we're not focusing on anything in a targeted way, right? And so that's the roundabout conversation that we're having. That over a five-year period, those focus areas might in fact change in our primary care, for example, or each of these sub areas based on what's going on or what's most needed in our community.

I mean, I think it would be helpful, though, to have something tied to that. So then when you are reporting out on the annual plan at the end of the year, and we can see how they are related to that spending plan is related to those metrics and those focus areas. I don't think it's an expectation that you have to. because this isn't like a grant, right? Where with a grant, you have to meet these specific metrics to show you are making progress in these areas in order to maintain those grant funds. These are taxpayer dollars. And as being the fiduciary responsible parties and stewards of these tax dollars and wanting to make sure that you are getting the best benefit of those dollars and the community is getting the best benefit. It just would be helpful, I think, for us to see how those things are aligning and knowing like, okay, and I think it would help all of you as well. It would help Denver Health to say, okay, we aren't seeing, we're seeing a decrease in this area or we're not seeing a need for this coming forward. And how do we then restructure how we're spending these dollars? i think that's absolutely fine so it's just about like having some transparency in that front um is all that i'm hoping for for sure thank you all right thank you thank you mr chair uh thank you pro tem uh look around the room and also virtual so there are any final questions

Seeing none, I have one question, CEO Lin. I know the anticipation for 2Q and the expectation, and I'll use the term donut hole, I don't know if you use that as well, to fill a donut hole of funding that Debra Health to meet the needs of all the community members across the state and Denver that are coming to you. Can you or your team explain a little bit of the impact or the sizing of that donut hole? Is that hole, is it meeting the need and what are you forecasting as far as kind of the need beyond what we just did with 2Q? What are we experiencing as far as the support 2Q is providing and what do you forecast? the shrinkage of that support is looking like.

So if I may, Mr. Chairman, I'm going to go back to 1997.

Do it.

Because the hole was growing and growing and growing every year that the MI payment was held flat for Denver Health. So Denver Health would have had, I believe, if the MI payment had increased at just a modest rate of inflation, we'd be getting... over $55 million this year from the city. But that was a choice that was made not to increase that for a whole variety of reasons. And the problem with that accumulated poll is the inability for Denver Health to invest like many other systems around the metro area have done, whether it's in new facilities, new technology, new staff. And so we have some other problems that other facilities or systems don't have. They build brand new buildings. They can, you know, like we're all going to have to invest in artificial intelligence. So we've done the best that we can with the money that we've gotten, but I would argue that we've got to go back to 1997 and should have gotten a lot more money. So we're digging out of the hole. Maybe the donut hole is the right analogy, I'm not sure. We have some challenges ahead and those are going to diminish our revenues, which will put a lot of pressure on the things that we can do for the city and for the patients that we serve. And I'm not looking forward to that 2028, 2029, 2030. We've been able, as you saw in the presentation, we haven't taken 2Q money from the place it was allocated to be, but in those areas we've been able to say let's make a few little investments to improve the care coordination our patients are getting and other areas. So I suspect that this year we'll get by. Okay. We did owe DERP a lot of extra money. So, I know Councilman Flynn, I'm shocked that you're restrained and not talking about DERP today, but... Are you glad you got any satisfaction? We have a big DERP liability that we owe the DERP system and that's one thing that we have to keep paying to meet the liabilities that we have for both current, although it's a small number, and former Denver Health employees. So I think we're, I won't even say cautiously optimistic. I'd say I'm cautious about 2027 and 2028. And as I said, there is a real need for us to invest in some of the infrastructure in our organization. And if we were, if our revenue was greater than our expenses, we'd be doing that like many other systems do. We also have a very low bond rating. Our bond rating is very different than the city's. You know, we are triple B. That is not a great, when we go out to borrow, we're paying a lot more to the lenders than the city and lots of other organizations that are financially in better shape.

I didn't know that. Thank you so much, Donna. Councilman Flint. I hate to disappoint.

Just an easy question, though. How many, because it was 1996, how many career service workers still remain at Denver Health? It's got to be diminishing year by year. It is.

It diminishes every year. It's less than 30. Okay. So it's less than.

We have a lifeline here. Waiting for it.

Hi, everyone. Megan Parizo. I work at DDPAG, Public Health Department. I just got this number from Finance a couple days ago. I think it's 19.

Wow. But that is the small piece of what we have, because those who retired under DERP and who live We're paying for them, and that's the majority. That's thousands of people.

Thank you. Thank you, Mr. Chair. Thank you so much, Council Member Flynn. I just wanted to share a point of personal privilege. This past week, we had a mini scare in my family with my mom, and it gave us such a sense of calm because she was able to get to Denver Health. I want to thank Dr. Federico, Dr. Reed, Pierce, all the nurses and everyone that took such great care. And I think these briefings and these meetings and discussions that we have, we talk about what we do at City Council. and the direct impact that they have on individual lives and Denver Health is one of the more unique because every day you are saving the lives of the folks that live in our city in ways that other hospitals may not have that opportunity because you're so trusted so my mom says thank you and I say thank you on behalf of her and thank you Dr. Federico for you know coming to my mom's that so with that we have one item on consent and it has been pulled off so look forward to seeing you all next week thank you thanks so much

Thank you.