Board of Supervisors - Regular Meeting

Good morning, everyone. I'd like to call the Stanislaus County Board of Supervisors to order. The date is May 5, Cinco de Mayo. The time is 09:03AM. I'm going to ask everyone to please stand for the pledge of allegiance and remain standing for an invocation from Dallas Jackson with Renew Church of Modesto.

Let's pray. Heavenly father, we come before you today with gratitude for this gathering, for the responsibility entrusted to those who serve our community. We ask for wisdom. We ask, as you just lead these members who are leading in many decisions they face, grant them clarity of mind and discernment of what is right and the courage to act with integrity. We also pray for encouragement to them. This work can be heavy and the responsibility great and the pressure constant. So strengthen them, we pray. Pray for them and their families. And today, we also lift up those who will be presenting and sharing today. Give them clarity of mind and speech. And may all that is said and done here today contribute to just the flourishing of this community. We trust this to you. I pray this in your name, Jesus' name. Amen. Amen.

Thank you very much, Dallas. Okay. We're gonna go on to item number three, presentation. We do have two presentations today. The first one is declaring May as behavioral health month and Ruben Imperial will be presenting.

Good morning chairman Kiesa council both CEO Hayes board of supervisors I'm here to speak on the declaration- for the month of May. As mental health awareness month in Stanislaus County. The reason why we do this is to communicate to the public and reaffirm the county's commitment to show support for those experiencing a mental illness. The goal here is that as I'm sharing this information with the community and the public that they hear that when it comes to a mental illness and receiving treatment for mental illness that they are not alone and that help is available for them and share with the community throughout the month of May the resources that are available in our community if you are experiencing a mental illness or a mental health crisis. And most importantly, every day we are reminded in our department and the communities we serve and the individuals that we serve that recovery is possible.

And if you get treatment and you get treatment early and you get treatment often that you can have positive life outcomes for yourself and your family. It's also a time to remind our community that in Stanislaus County, behavioral health and recovery services is one of many partners in the community that provide treatment services. The county is the behavioral health plan, the Medi behavioral health plan, and we primarily serve individuals that are covered with Medi Cal and beyond the Medi Cal treatment services, we also act as the mental health crisis services for the county as well. We also have other partners in our community that fund mental health services. Our Medi Cal managed care plans, like Health Net, Kaiser, Health Plan at San Joaquin, they also fund mental health treatment services.

Their services that they fund are primarily for individuals that have what's called a mild to moderate mental illness. The county services are for those that have more of a severe or serious mental illness. So behavioral health is not the loan funder or provider for mental health services. We also have our Medi Cal managed care plans that fund treatment as well. We also are complement our services are also complemented by the commercial and private health insurance.

They also, by law in the state of California, are required to provide mental health treatment benefits. These services are provided through a variety of partners, and you see on the slide here, there are major community based organizations in our community that provide treatment services. There's some familiar names like Center for Human Services, Golden Valley, Sierra Vista, Turning Point, Telecare, Aspironet, so on and so forth. And the reason why that's an important message for the community is oftentimes when individuals start to experience a mental health, they question where they can get help. And we want folks to know that at the first signs of a mental health issue in your family or yourself, you can call your commercial health insurance.

You call your Medi Cal managed care plan. It does not have to get to a point where you are in a crisis and end up in an emergency department. So for those that may be experiencing a mental health crisis and it's not impacting your life every single day in a serious way, we would like to educate the public that you can call your commercial health plan, your employer covered benefits, your Medi Cal managed care plans, and get treatment early before it gets to a crisis. And these are all of the great partners in our community that provide these types of mental health services as well. And then lastly, it's very important to know that if it comes to a point where an individual does need help and they are in a crisis, Stanislaus County has a 20 crisis and support line.

It is operated by county staff and they are trained professionals who can guide individuals to the right service or help with a mental health or substance use disorder crisis. So that's also a very important message for the month of, the month of May. If it does get to a point where you need help and you are in crisis or a loved one or someone you care about is experiencing a mental health crisis, you can call this line and folks will help you. And again, over the last couple of years, this line has grown. Our capacity has grown not only to answer the call 20 fourseven, but we now have the staff capability to respond to mental health crisis calls in the community.

So now through whether someone calls 911 or a crisis line, over the last couple of years, we've increased our capability. We were now able to go out into the field and into the community. So that's another important message through the month of May. We want our community to know and we'll be working to promote these services in our community, all with the aim of improving and increasing the health and wellness of those individuals in our community that are experiencing a mental health issue. So with that, take any questions.

Ruben, thank

you I

to invite our behavioral health board member that is here with me, Lauren Menarche, a local licensed clinical social worker and she is here with me on behalf of the behavioral health board to receive this proclamation. Thank you.

Ruben, just real quick. Thank you for what you're doing. The need out there is probably greater than ever. But I can see in the sixteen years that I've been here, the work you guys are doing now more than ever is needed. But it's just amazing what you guys are starting to accomplish out there. Like you talk about being out in the field and being able to get out to the people to where they are that need the help. The stigma around mental illness seems to be disappearing. It's just not there like it used to be which is great which allows people to feel comfortable and ask for the help. And just very exciting to see the work you guys are doing and what a difference you're gonna make in our community here. So thank you very much for all doing.

Very good.

So about, I don't know, seventeen, eighteen years ago, when I got on the board, there were a few board assignments that the supervisors didn't want or didn't have time for. And one of them was the mental health board along with trains, children and families commission. I can remember each one of them. And the mental health board was one of my first assignments. I loved it.

Terry comes on two years later and makes me Rochambeau him for, and he's been on ever since because we both wanted the assignment of sitting on the mental health board. So there are ebbs and flows in all of our departments, whether it's the health services agency, whether it is the behavioral health and recovery services, whether it's veteran aging services, there's ebbs and flows in money depending on community need. What we've seen now is we've seen a tremendous influx of money because the issue of co occurring disorders, mental health is not a stigma anymore, which I think it was if you look back twenty or thirty years for families, but people have a much better understanding of what it means, to get better and to get treatment just like you spoke about. So there it's changing, you know, have these briefings all the time about where the money's going to go or how it needs to be deployed. But every one of these, as supervisor Wizzer talked about are making a difference in our community.

It's truly, truly amazing. Very proud in this county. And, you know, Ruben used to be in the CEO's office and now he went back to his original love, which is as the director of behavioral health and recovery services. And the mental health board, we just had a meeting. This is district two's appointee to the board, but we just had a discussion about, the great things happening there and how we need to get the message out to the community on all the good things that are happening.

So anyways, on behalf of the board, and I'll read just a few of these, proclaiming May 2026 is Mental Health Awareness Month in Stanislaus County, whereas the Stanislaus County Board of Supervisors has recognized supporting a healthy community as a priority, whereas there exists a direct correlation between the mental health and overall personal health, and whereas mental illness and substance abuse disorders affect almost every family in America. Whereas individuals living with mental illness and substance use disorder can achieve recovery when provided with appropriate services and community support. Whereas stigma and the fear of discrimination prevent many individuals who could benefit from mental health and substance use disorder services from seeking the help they need. So we're reaffirming our commitment, to mental health in Stanislaus County with this proclamation and therefore be it resolved. The Stanislaus County Board of Supervisors does hereby proclaim May 2026 as Mental Health Awareness Month in Stanislaus County.

Next presentation is Tom Stettlemeyer. Hopefully, I said that right. And this is on the retirement board and our retirement rates.

Good morning. First of all, you very much for having me and more importantly, thank you for the support that you offer to Stancera. And really our goal is to help provide a financially secure future to the employees and the retirees that have served the community, have worked for the county and other employers that are part of Stancera. My presentation will be fairly brief this morning. I don't know if it will load up there.

And then I'll use this to move forward. Okay. So we'll talk about kind of we'll give you guys a basic financial update of the plan and how things are going. And then we'll also spend a few minutes talking about a few of the things that we're working on at Stancera and some of the trends and issues that are affecting Stancera. So I started with this, you guys may have seen this before, but I think it's a for me it's a helpful visual that simplifies a little bit what we're doing in the pension fund and how the money comes in and comes out.

So it kind of represents a water tank showing the funds that are set aside for the benefit of members of the plan to meet the obligations of their pension benefits. And there's money coming into it a few different ways. Obviously, the county makes a large contribution as the employer and that's represented at the top with those blue pipes coming in. In the last year there was about 126,000,000 that were contributed to the fund. Employees themselves also contribute significantly to the fund.

Last year, it it was about $38,000,000 in total that went in. And then the biggest input that the fund relies on over the long term are investment earnings in order to meet those obligations. So that's the yellow pipe coming into the fund, which last year it was a positive year in terms of investment earnings as the markets were doing relatively well and there was about $278,000,000 additional moved into the fund. There are two main outputs that leave the fund. One, our administrative expenses, are a small piece of about $4,000,000 We'll talk a little bit more about that in the presentation and how we look at that.

Even though it is a small piece, it's a piece that we and the Board of Retirement controls. And so we like to focus on that and think of that as being good stewards of the funds that are entrusted to us on behalf of the members. And then the largest piece that goes out and the reason we exist are those benefits that are paid ultimately, which are approaching $200,000,000 annually that are paid out members of this community that have earned those benefits through their service to the community. Here's kind of the boring chart as it relates to that. And I'll just kind of focus on the trends on the right hand side in terms of how things went down last year.

Generally speaking, everything was higher. The markets were up and that led to positive investment growth. Contributions from both members and from the employers side were also up fairly significantly. A lot of that is driven by if you have pay increases, you're going to generally speaking see increases in the contributions that are also put into the pension fund. And so we did see that.

We've seen that as a trend over the last few years. And then in terms of administrative expenses that is one area we focused on trying to be more efficient as an organization. So we did see that figure drop slightly. In terms of liabilities that are owed to members those also increased not quite as much as the benefit or as the investments increased, but we did see a slight increase in the liabilities that are due to both general employees and safety employees up by a little bit over 4% over the course of last year. Here on this page, we just have a snapshot look at the trend of the investment earnings just over the last five years.

And then on the left hand side of the chart, you'll see kind of the long term performance of the fund over time. We do have an assumption that is set by the Retirement Board of how much earnings we expect to earn on an annual basis over the long term and that's based on historical information, comparison to other funds, looking at the market and looking at the economy and advice of our consultants and experts and the Board has set that rate at 6.75%. And you can see over the long term, we generally track right around that area. Over the last twenty years, it is 6.7% interestingly enough. And you'll see over short term periods and some long term periods, we'll do a little better, sometimes a little bit worse.

I don't have it listed here on the chart, but the longest period we go back to in terms of tracking is back in the 1990s and since that period, we're a little over 8% in terms of the investment growth over time. And the other thing I always like to point out on this is a lot of this the investment growth is going to be a function of how much risk does the Board choose to take on. You can choose to take on a lot of risk and shoot for higher returns, but at that point in time if that occurs, could be at risk of losing a significant funds which would lead to the county having to make a much larger contribution. So the Board weighs the benefits with the risks and ultimately the goal is to try to hit that assumed rate of return. One of the key features that the county will have an interest in over time is budgeting for these contributions to the plan.

And you'll see you know, you'll be reminded from previous years presentations that we've done that every year we evaluate, we work with our actuaries and we evaluate how the liabilities have changed, how the assets in the plan have changed and we set a per our funding rules that the Board's put in place, we set what the contributions required will be. And in the last year because of the especially because of the positive growth and also because of meeting our assumptions on the growth of liabilities for the most part, The contribution will actually go down slightly this year, which is a positive thing in terms of the budget for the county. And then you can see over time, our expectation is over the next decade or so that contribution rates will be fairly steady. Now, you always have to keep in mind and this is what the bottom chart on the page shows. That's

going

to change year to year, based on how the market does, based on conditions, based on how many employees there are, what pay increases are, over time you're going to see adjustments to that contribution rate. But if we projected into the future and hold everything as assumed as we assume it will be based on the evidence that we've seen and what we understand about the future, then we should expect pretty steady contribution rates over the next ten years or so. And then you'll see in about 02/2038 time period, there will be a very significant drop off in the required county contributions. And what that's related to really is paying off or an amortization of old debt that was accumulated in the fund primarily related to negative market conditions right after the GFC around 02/2010. So the plan is diligently working on paying that off through the funds that are offered through the county and other employers.

That's on a good track. But every year to year based on market conditions that could change and could lead us to a place where the contributions won't drop off quite as much in the future or if market conditions are tremendously good over a long period of time, it could be that the contribution that the county offers goes down more quickly. So that's something that we'll track year to year and provide an update to this board on as well. And we also work closely with the county keeping them up to date on any of those financial trends that we think are important. It's going to take a couple minutes here based on feedback I've received to just talk about where does Stancera fit in relation to our peers and to the other pension, local pension funds in the state.

What you see on the screen here on this page is a list of the 20 counties that are part of the 1937 Act pension funds in California. So we call these the SIRL or County Employees Retirement Law systems. And you can see Stancera is one of the smaller funds. We have little over 11,500 members and as of the end of the last fiscal year we had about 3,100,000,000 in the fund. So that's the I believe sixth or seventh largest fund or I'm sorry smallest fund in the system.

And all of these systems are essentially running the same plan with the same benefits and the same using the same set of laws. So it's interesting to kind of compare and contrast where Stancera sits versus those other funds. And the next page does a kind of a summary of that looking at where Stancera sits versus first set of comparable counties. So there are five comparable counties that also have SIRL systems that would be San Joaquin, Tulare, Kern, Fresno and Merced. And then you also have a line item there showing what the all the averages across all the Searle systems.

So you can see when it comes to the other Valley counties, Stancera is very similar and kind of the characteristics of the Valley Counties are that they tend to be more fiscally conservative than the rest of the counties and the rest of the state. The expense per member is actually significantly lower than the other counties, which is interesting because they tend to be smaller size plans, but they've still been able to be more cost effective than the larger counties that are tend to be on the coast and then Southern California. And the funding ratio actually tends to be slightly lower due to multiple factors. So the major factors why the funding level in the Valley Counties which is around 82% is a little bit lower than the other counties overall which is 88% really relates to contribution policy, investment policy and investment returns. And I would say the main driving factor is the contribution policy.

The Valley Counties tend to pay off that debt that was accumulated over a longer period of time and many of the other counties have been a little bit more aggressive in paying off that debt over a shorter period of time. Stancera did move in the last few years to a shorter amortization period. So any negative impacts on the fund are paid off over a fifteen year period now, whereas previously in the past it was thirty years. So that's a positive change that will result in the fund being 100% funded and a quicker basis if there are ever any negative impacts. I was going to take just a minute or two and talk about administrative expenses in public pension funds.

And what's shown on the screen here is a chart that shows in the green line the national average for the cost of administering public pension funds as an expense per member and then the yellow line is the cost in California. And what you can see here is that the cost of administering public pension funds in California is significantly higher than the rest of the country. And to me, I look at this and I see this as a huge opportunity for improvement in California. You know the means exist to administer the plans more efficiently and more effectively and that's something that we're focused on at Sansera in terms of you know making good use of the funds and being good stewards of those dollars that we hold on behalf of the community and of the members. If you look on the right hand side of the screen, it's really the directive under the California constitution of what the retirement board does, which is that they shall administer the system in a manner that will assure prompt delivery of benefits and related services to participants and their beneficiaries.

But it goes on further to say that the assets shall be held for the exclusive purpose of providing benefits to the participants in the pension system and their beneficiaries and to frame reasonable expenses of administering the system. And so I think we have an obligation and our board recognizes that there is an obligation to make sure that the expenses that we incur as we administer the fund are reasonable and there are techniques that we can employ to achieve that goal. At Sansera that's been a focus over the last few years and we have actually reversed a trend of long standing increases in expenses. Over the last two years, we've actually decreased the expense per member by 13%, which is a significant achievement when you look at what the trends have been over time. Pension funds are complicated to administer.

It's one of the more complicated benefit types of retirement benefits that you can administer. It has a ton of positives to it, but they tend to be more complicated. There are complicated formulas, a lot of information to track. You create all these different tiers of people with different types of benefits and the complexity adds to the cost. But there are techniques and there are things that can be done to the expenses more reasonable over time.

And one of the things Dancera invested in was a system to further automate some of our processes and we've been able to take advantage of that to create a more streamlined process that essentially gives better services to employees at a lower cost. And we're implementing those techniques and having some success with it. And why this matters? In the long term being efficient will help keep long term contribution rates more steady. The way we look at it, we're providing a supportive service to the county.

So every dollar we save is an extra dollar for the county to spend on important initiatives in the community like the behavioral health, public health, public safety and other things that this board works on behalf of the community. So we think that's an important thing that matters and we're going to continue to focus on that under the direction of our board. Just going to spend a minute or two talking about artificial intelligence and how it affects pensions. This has a really hot topic. I'm sure you're hearing about artificial intelligence all over the board in terms of many different topics in the community.

But it does have some unique effects on the pension systems and pension funds. And so just talk for a minute or two about those themes. The first one that's kind of a big theme are our investments and then the investment side of our work. Obviously, it's critical to our members and to this to the financial health of the system that we continue to earn good earnings and meet those goals that we have in place, so that we can kind of stay on the budgets that this Board is expecting. And in terms of the investment side of things with AI, it's going to have a big impact.

And so then there's different ways to look at how AI will affect the investment side of what we do. The first thing is there's going to be companies that focus on AI, right? And you guys have all heard of the Anthropix and the OpenAI's and of course all the kind of big players like Microsoft and the other kind of large companies Amazon, X and so forth. They have businesses that are directly investing in AI tools that will be used by society at large. And one of the things we don't know ultimately is which of those companies will succeed.

Some of them will be huge winners and those products will be used across the board by everybody and so there will be financial benefits to investing in those companies. Some of those companies will fail and will not work. This is just the way it's going to work. We can't necessarily predict which of those companies will succeed and which will fail. But I think from an investing thesis standpoint, it goes back to the kind of the oldest word in investing diversification.

And it's going to be critical in terms of managing the risk for public pension investors that we have some investments across that space. And that doesn't just include the big names that you know about, but there are many smaller companies as well that are investing in AI tools. And some of those will become very successful over time. So we're taking an approach of diversifying when it comes to that. Secondly, I think we need to recognize all companies in general are going to be utilizing these technologies to improve their productivity.

So we should as a general rule see an increase in productivity in all these different companies and the investments that Stancera participates in, which should over the long term rise the tide for everybody. That is something that again we'll have to track over time. And we also have to keep in mind that there will be some companies that will be threatened by AI. There will be software companies that for example have focused on a particular need that AI may be able to do much quicker, much faster with much less expense. And so we're going to see across the board a series of companies that do well and are big winners on the investment side and others that will be losers.

And it's important for us to manage that risk and diversify across the board. The other thing to keep in mind here is there's a lot of, I would call it hype as it relates to AI and a lot of speculation as it relates to AI. And I think it's important, the markets will very often have bigger reactions and then over time kind of settle back in as those technologies are better understood. And we're definitely going through a period where understanding the technologies and how they can be used and how they can benefit people and companies. We're still in that period of trying to understand that as are the developers of these technologies.

So it's something we're going to have to track closely. Two other quick themes that kind of affect pension funds as it relates to AI. One is going to be you know we do anticipate there'll be a long term impact on longevity. You hear a lot about the focus on improvements in health outcomes over time. So earlier and more accurate disease detections, better health management, AI acceleration in terms of drugs getting approved.

So there's going to be a huge in all likelihood positive impact on the potential to extend lives and extend people's health, you know, instead of people being healthy into their 50s, 60s and 70s, you may increase that a decade or so. And all of that together is going to be, know, a very positive impact on people and on society in all likelihood. But it also from a pension perspective, it could over the long term increase our liabilities. More people could be working longer and we also could have in addition to that longer lives, longer time periods that we need to pay out pensions and it's something we'll have to continue to track. So that's something we don't necessarily have a firm grip on, but it is going to be an important trend over time that we'll need to take a look at.

And then the last piece, we're going to be utilizing these technologies just like every other public pension organization and every other company to improve our productivity, right, to enhance the tools that our employees use to better serve the members of the fund. And ultimately, I think a huge part of that will be to help us to even further reduce expenses and do a better job of being able to take care of the members' needs and reserve more money for the community to use for the important purposes that this Board assist the community with. With that I'm just going to close by just recognizing the Stancera Retirement Board which sets the priorities for Stancera and makes the decisions at our board meetings. We have a wide range of people that come from various disciplines that weigh in on the decisions that are important to Stancero and especially on the financial health of the system. And I just want to personally say thank you to this group for what they offer and I know that they are very interested always in understanding the County's perspective and anytime that any member of this Board of Supervisors or County officials have questions, concerns, topics, things we ways we can work better together.

I always want to offer that's something we're interested in. That's something our board is very interested in and you know it's important for us to keep those communication lines open. So, I do appreciate the partnership we have with the county. And, know, I'll stop there and see if there are any questions.

Good report. Any questions? I'll let the resident CPA go first.

No questions. Just Tom. Thank you very much. Great presentation. Just I love the chart where you show the money coming in, the money going out. It's three has it been three years you've been here at SandStreet?

A little over three and a

half years. Yes. Okay. Yeah. I know. Do And you're just doing great work. Just yeoman's We're so much appreciate all you're doing. And it is a complicated system as you say as you say. The you know, as far as in the world of pension plans, defined benefit plans are the most complicated of the types of plans. I say this all the time but in the private sector, defined benefit plans went away about thirty or forty years ago because they were bankrupting companies. Because they're that hard to manage and very expensive to run. So so I appreciate all the work that you're doing. It is, like you say, to try to reduce the expenses, to try to That's a great thing for the county. We very much appreciate that and all the hard work you do for that. And just glad that you're there and the work that you're doing.

It's great to see that percentage go down a little bit this year. That's always welcomed. I know it's gone up before. That's just it comes and goes. And the other thing just to mention is, you know, our county is debt free with the exception of our unfunded liability. And it looks like as we see in the charts here, you can see about eleven years from now that this county will be totally debt free if all goes well. I know that's, there's no guarantees in that. Like I said, it's a balancing act to try to work through this thing, but that's very encouraging to see. So anyway, thank you. You're a superstar in what you're doing and thank you for all your hard work. Thanks, Terry.

Very kind. I know I

acknowledge Doris who I can only see a little bit of her. Doris back there and Donna over here. Thank you guys for your service on the board. Any other questions? All right. Seeing then. Thank you very much, Okay. Now we're going to move on to the item number four, which is the public comment period. We don't have any written comments. The open public comment period is time for those in attendance to speak on items not already on today's agenda. Please state your name for the record, direct all comments towards the dais. And so it's fair for every speaker, please limit your comments to five minutes. I have one speaker card, Brian Abbott. Good morning, Brian.

Good morning, you guys. Anyway, mental health. We kinda create this mental health in our own ability because we don't take care. Here's somebody's little tagging up here. But what happened is some of the kids these days, they see brutality from our police departments. They see this brutality and then they grow up. We have a cat officer, which is care after trauma that usually we'll send out there if one of our officers have been involved in actions against a family. That way we can keep it all calmed down and everything. But sometimes it doesn't work that way. The kids get threatened too.

They see their parents and their family beat up by the people that are supposed to protect them. And then they wind up growing up with mental health. And then we wind up spending a lot of it because they're discouraged that they can't have any faith in our system by protecting them or their families. So then they go on to drugs and then we turn around and supply the drugs through our hospitals and we give them. And the same thing we give the parents because now they're under stress. So we keep creating this because we don't start in the very beginning. The protection of the family unit, the protection of the way that they feel, the way that they see our officers. And this is really terrible. And we just keep on throwing more money at it. It's okay.

It's okay. We'll just throw money at it. And then we'll turn around and we'll lower the charges on the family so that way they don't have it. No, which is manipulating the family to where they're just breaking apart and the kids aren't sticking around and they're not working. And that's easier for them to steal than it is to go to work because they know, oh, it's okay to do this because nobody will do anything.

They'll just give us drugs and say, oh, well if they give us more drugs then the schools can get more money. If the kids are raped, the schools get more money to educate that kid. And then we give them more money for more counseling. And who do we take that from? The same family that we created the problems.

And then when the parents die, we seem to just sit there and take their homes. Because those kids don't know what to do because they're on drugs, the homes are lost, and we pick those homes up, and then we wind up turning around and selling them, and then we put the money back into rehabbing these kids. And the same vicious cycle goes over and over. We can't just keep throwing money at it. That's not the way we do it. We need to change the way the system works. When the police officers come out there, they should be more like social workers. Protect the families. It doesn't matter what it is. We can't let the criminals get away with everything.

We already do that. We give them a pro bo attorney. All criminals got to do is say, They threatened me. Oh my God. And the property owner gets hauled off. And he gets beat up, and the kids are there watching it. Now this is getting ridiculous that we do this. There's gotta be a change in the way that that action happens. And it starts with our own police departments. And when they falter, you guys are here to turn around and pick up the best.

Don't just push it off and then sit there and you go into court all they want is your money. Now they're just taking money from the family under false charges that were just presented by an officer where there's no backup, no back check. And yes, AI is going to do a lot better because there we go. Now the scenarios could be placed into a hands where AI could turn around and tell that officer. We just get an officer out of high school. He doesn't know anything. He's used to playing high school games and now we put them on the street. And then they grew up and we keep on saying, good job, good job. They're not doing a good job when they harm the families. Because that goes on and on and on.

Next thing you know, ran the good kids out of your town and you kept the bad kids in here that you created. I have a daughter and another one, the same thing. And they had to see that happen to their dad for no reason because a beggar woman broke in and then the cops broke into the house. And then they turned around and beat me up for coming over there. And then my kids had to see it.

And you

had to have cat officer care after trauma. She's telling us she's going to arrest my kids after watching them point guns at us. This is our own sheriff's department. And this is your cat. They're not trained properly. They need to change this. When you go out to a family and there's kids involved, you take precaution. You take care. You don't just send men out there. Oh, but they're in combat here. Whatever, we don't even know the story. We only got it over the line from 09:11. They just come out there like they're frigging army man to attack whoever. They don't care. They got to have caution.

And I've seen this and I've lost a lot of money right here. And you guys have never turned around and replaced it. Never. And Bose, same thing. He sits there and he gives out $50,000,000 for our last sheriff that was a loss. 50,000,000. But he wouldn't even give a dime to my kids that turned around to watch them Thank

Thank you. You.

This this has to change. You put the little green things on.

Anyone else for a public comment? That's my last speaker card.

They are helping. They create the problem.

Okay. Seeing none, we'll close the public comment period. We're gonna move on to the consent calendar before we take any action on the consent calendar, would anyone like to comment from the public? Anyone of the board members like to pull any items? Seeing none, left to right, entertain a motion for the consent calendar as presented.

Motion to approve all consent calendar items.

Second.

The motion and a second, I'm just gonna hold on for a second because I don't wanna see the big exodus yet. All those in favor say aye. Aye. Opposed? Motion carries five zero. Thank you.

They're afraid to get up.

Okay. We don't have any public hearings. Item six, so we're gonna move on to discussion items. Item seven, first one is approval to accept the 2025 public health annual report from the Health Services Agency. Doctor. Papa, Alicia and Heather will be presenting.

Thank you. Good morning, Chairman Keyser, Supervisor, CEO Hayes and Council Boes. I'm so pleased to be here today to introduce and kick off the 2025 public health annual report. We typically come to you in April or early May to align with national public health week. The theme for national public health week this year is ready, set, action.

This sets the tone of what we're doing. We're recognizing what public health has accomplished and taking active steps to create a healthier future. Public health plays a critical role in our daily lives, protecting our families, extending life expectancy and strengthening our community to thrive. In 2019, you may recall we became an accredited public health department. This is a five year process.

And this last year we completed about an eighteen month big lift, and I really have to compliment our team of submitting over 115 documents to support our work and share how we have met the standards required. During that time, we had an on-site visit that just, it was virtual, but it was a site visit through the Public Health Accreditation Board a couple of weeks ago. And I want to call out to Supervisor Keza and Supervisor Buth Condit, part of that accreditation process to interview our governing body entity and that is you all. And they came and met with the FAB reviewers and just did a tremendous job highlighting the work that we do with your board and the communication. And I know you all have busy schedules, we really appreciate that support.

And I'm happy to say that I'm very confident that later this summer we will be hearing that we are accredited public health department and we'll certainly let you know when that happens. And now I'd like to turn it over to our presenters today. We have our public health officer, doctor Thea Papasazomenos, and our assistant public health, director, Alicia Sanders.

Hi. Good morning. So we'll start off sort of on a, I guess, a more serious very serious note. So this slide is looking at our top five causes of death, age adjusted per so the numbers are per a 100,000 of our population, and it's looking for the year 2024. So for 2024, our top causes of death our top cause of death

was

heart disease, which

is

usually that's that's a long trend nationwide and in our county. So our rate of heart disease accounted for twenty four percent of deaths in our county for 2024. And our second highest cause for death was cancer. And cancers accounted for nineteen percent of deaths in our county in 2024. We also have dementia, which account, which accounted for seven point six percent of deaths in our county.

So looking, so when you add up all these individual causes of death or groupings of deaths, you come up with what's called the total all cause ages death age adjusted death rate. So that adds them all up together. And so for Stanislaus County in 2024, our total all cause age adjusted death rate for 2024 was eight hundred sixty nine per a 100,000 of the population. And in 2023, it was nine hundred point eight. So we we we had a decrease in our total all cause all cause age adjusted death rate.

But if you look at that age adjusted total all cause rate compared to California as a whole, it's higher. So for California, it was six hundred twenty four. So compared to hours of 08/1969. And then for The US, if you look at the all cause death rate, it was seven hundred twenty two per a 100,000 in 2024. So that means that our all cause death rate is higher than both California and The US.

And the reason why I mentioned the all cause death rate is that death rate and life expectancy are that you see in the community are two flip sides of the same coin. So they're key summary measures that are inversely related to each other. So as death rates increase, life expectancy declines. And conversely, as death rates decrease, life expectancy increases. So if we have higher death rates overall, that means our life expectancy compared to The US and California are gonna be lower.

So for Stanislaus County, our life expectancy in 2024, the total was for both males and females together was seventy seven point three years. And in California, that traditionally has a higher life expectancy out of many states, the total was eighty one point two two years. And in The US overall, in 2024, it was a total of seventy nine years. So while these measures in general, while these measures all worsened during the pandemic for both for all, you know, for The US, for California, and for Santa's laws, they rebounded. And and they are for the most for their they're all pretty much life expectancy and all cause death rate are back to a direction of improvement, which means they're steadily death rates are steadily going decreasing, and life expectancy has rebounded since the pandemic.

Next slide. So now we're just gonna do a deeper dive into, two of our top causes of death in our community, heart disease, and then later cancer. So looking at heart disease, heart disease is a very broad category of diseases. It groups together a whole bunch of different diseases, including things like valvular heart disease, congestive heart failure, ischemic heart disease, and hypertensive heart disease. And then this graph is looking specifically at Stanislaus County heart disease, cause of death, the death rate from 2019 to 2024.

And as we pointed out, our death rates are higher. That includes for the individual conditions. So our death rate from heart disease is higher than California's overall and then higher for the higher than The US as well. So for from the previous slide, our heart disease in 2024, the death rate was two zero six point nine. And then for The US, it was one fifty seven point six.

Six. So a large you know, a a significant difference. So but you can see overall in this trend, this is just looking at six years from 2019 to 2024 that this is trending downward, which is good. And that's how you want it to go. And if we push this graph further back, going back to 2,000, and then going even further back to 1970, you will see for Stanislaws, for The US, for California as a whole, that this line has dramatic you know, has had sustained and long term decrease in deaths from heart disease.

Next slide. So what's driving what's driven a lot of the decrease in deaths from heart disease is the decreased deaths from what's called ischemic heart disease. And like I said, ischemic is one of the types of heart disease. There are different types of heart disease. But ischemic heart disease is heart damage that's caused by narrowing of heart arteries, also known as coronary artery disease or coronary heart disease. And it's the main cause is due to arthrosclerosis or plaque buildup of the heart vessels, and it's the most common form of heart disease. It is the leading cause of heart attacks. And so we have the good news is we have all sorts of interventions now to target heart disease. We have cholesterol medication. We have bystander CPR.

We've had made tremendous advances in interventions for acute heart condition or acute heart attacks. We have stent placements that can now open up the heart vessels and keep them open. So the great news is that people are surviving acute events like heart attacks, or we're able to prevent and control arthrosclerosis so that people aren't even having heart attacks. And the con oh, go back. Sorry.

So, and the consequence of that is that people are living longer. And now, now that they're living longer, they have the opportunity to develop other heart conditions, like hypertensive heart disease. So you can see the the flip side is that while things like ischemic heart disease go down, things like hypertensive heart disease start to go up. But if you look at the whole story, it means overall people are living longer, and that's why they're able they're they're developing other heart conditions. Next slide.

So this is looking at our cancer death rates. And as we pointed out, California has higher cancer death rates than California does and for The US overall. So The US rate for, for age adjusted cancer death rates in 2024 was a hundred and thirty nine point four compared to Stanislaw's at one fifty five point three. And the Healthy People 2030 target is one twenty two point seven per hundred thousand. So we have a lot of room for improvement with this metric.

Healthy People 2030 are targets that are set by the US Department of Health and Human Services for, a lot of, conditions of where they wanna be, as a population overall, and they set usually ten year goals. So the next goal we have is for 2030. So I will, I'll come back to that, with when I talk about various things. So but what we can see overall is the trend data here. So over the last so just from this time period from 2014 to 2024, just like in California overall, our, deaths due to cancer have have declined.

So we are following, that trend data of a decline in all cause, cancer deaths. And this mirrors what we see in The US overall over the last thirty years, that the risk of dying from cancer has steadily declined in The US. Next slide. So, diving into, further some of the leading causes of death, the specific types of cancer, that contribute to our all cause cancer death in our community. We have, twenty five point six per hundred thousand that die of lung or bronchus cancers, followed by breast cancer, then prostate cancer, and then colon or rectal, or rectum cancers.

So these are the four leading types of cancers in our community. In the report, we also the public health, the actual, report, we did provide, additional information on all cause mortality, and we delved further into, all cause mortality as seen by race and ethnicity. And when we looked specifically at cancer death rates by race and ethnicity, we could see higher death rates in the white and black community members compared to those of Asian or Hispanic race or ethnicity. And we also see some of these same differences when we look at death rates by specific types of cancer. Next slide.

So this is looking at some of our maternal health data. This is looking at low birth weight at birth, and this is comparing different years, and it's comparing Stanislaus County and California. And overall, we are doing, you know, better than or comparably to California, with fewer babies born with low birth weight. So that's good. Go back one slide.

Yes. So this slide is looking at infant mortality broken down by race ethnicity for Stanislaus County, and it's broken down by by different age years. And I I did I brought I brought this slide in because just to highlight that we did see some just health disparities between our two main sectors of our population, which are comprised of whites and Hispanics. We were seeing a larger a higher infant mortality among whites compared to Hispanics. But that has since narrowed for the most recent cohort.

And so when we looked, we tried to do a deeper dive into our data and some of the things we saw, at least, were that white infants showed a higher proportion of deaths related to neonatal conditions and congenital anomalies relative to their total deaths. And so that was one thing. Next slide. This is actually this is looking at our suicides, our rate of suicide per 100,000 in our county for 2024, and this is actually good news. This shows, you know, compared to California, our suicide rate was less than California's.

And if you look I don't know. I'm sure y'all but last time I came here, actually, if we're looking at 2023, Stanislaus County had a higher rate of suicide. So for whatever reason in 2024, we had we saw a large decrease and our rate of our suicide rate declined relative to California. So that's very good. Next slide.

And this is actually delving a little bit deeper into the suicide data. This is looking at the actual crude numbers, the actual numbers of suicides in our community. And you can see that in 2024, we did have that big drop in our suicides all the way down to thirty nine, which is very good news. And then prelim data for 2025, I just received it was I believe it was fifty three for 2025. So an increase from 2024, but still overall a downward trend from where, it had been, or less than it had been. So that's that's good news.

Can you tell me what's crude?

Crude Oh, yeah. I'm so sorry. So crude, actually, when we say crude numbers, that usually refers to the actual number. And when you look at crude rates, that means the actual number divided by the population that you're looking at. When we say age adjusted, what that means is like we're we're standardizing the data to account for differences in the relative age.

Because if you wanna compare groups, we don't want age to be a factor in comparison. So when you look at, you know because people, for example, different populations have higher, you know, different ages have higher death rates. So if you have a population that's older, you're gonna have more people dying. So you wanna standardize that so you are able to compare what you're actually looking at between two different groups. So you can compare The US to California to, you know, Stanislaus County. So you get a better idea of what's going on in comparison.

Thank you.

Mhmm. Next slide. Yeah. So this

is looking at our deaths for from opioid opioid use. And, again, this is age adjusted death rates in our county compared to California. This is not crude. These are not crude numbers or the actual numbers. This is age adjusted. So what this graph is showing is that we did have also similar to the state. We also had a peak in 2024 and that we did have much higher rates of opioid deaths compared to California, but that luckily those numbers have trended downward as well, or have started to come down and they were lower overall in 2024 oh, I'm sorry, in 2025.

So next slide. And then this is going a little

bit further into that detail and is looking at age adjusted date deaths from opioid overdose, but breaking it down by race and ethnicity. And so we could see in our population, we had higher rates overall in our black community and our white community compared to Hispanic and Asian members of our community.

Alright. So now I'm thank you, doctor Papa, for talking about the health trends in Stanislaus County. I'm now going to transition us to talking about what we're doing about that as I talk about the programs and services that we provide. I'll also bring your attention to the three little arrows that you'll see throughout the slides. Those activities are also things that we're tracking in our plan, in our three year strategic plan.

And so when you see that, just know that we're using results based accountability to track those activities as well. All right. So first up we have well, I'll also say that when we talk about the services and the programs that we provide, we like to break them up into four different buckets. And so the first bucket is supporting children and families. We also provide education and outreach, policy systems and environmental change, and we like to strengthen community connection.

So I have just four slides to talk about those four things. And in this first slide for supporting children and families, I like to think about why is this work important? And so when I'm thinking about that, I like to talk about community metrics. So as you can see here on the slide, this work is important because in our community when we look at infant mortality, is doing a little bit higher than the state with five versus California, having four deaths per 1,000 live births. So we're doing a little worse off than California in that area.

And when it comes to child mortality, Stanislaus County is at a 45 when it comes to child mortality deaths per 100,000, and California is at 38. So we're trending a little bit higher than California in that area as well. And when we look at teen birth rates, Santa Claus County is also high there with 17 births per 1,000 for females aged 15 to 19 compared to California who's only at 12. And so that's why it's important for us to do this work around supporting children and families. And it's not just us, it's us and our partners who are contributing to these, moving the needle on these community metrics.

So with that said, we do have some programming to support children and families. And one of them is our Family Health Services Program which improves access to core services and decreases health disparities for pregnant people, children, infants. And last year in 2025, our programs visited 3,938 homes to support maternal and child health. We also have a medical therapy unit program which serves children from birth to age 21 who need medically necessary occupational and physical therapy services and medical equipment through the assistance of case management. And so in that program, we were able to receive 56 new referrals to that program for children.

In our community wellness program, we are dedicated to policy systems and environmental changes to improve the health and well-being of Santa Claus County residents. And in that program, we inspected 427 car seats and corrected two seventy six car seats to improve child passenger safety. And lastly, just as a highlight, we have a children's medical services program which provides preventative health, dental health education, and then lead prevention and medical case management for children birth to 21 years old. And in that program, we provided lead poisoning case management for children, sixty one children in our community. Alright, so next we have the next bucket that we have is education and outreach.

And again, looking at the community metrics, we're actually doing a little bit better than the state in some of these areas. So when we look at our chlamydia rate in Santa Claus County, we're at four eleven per one hundred thousand compared to the state who's at four ninety four. For flu vaccination, we're trying to catch up to California. We're at forty one percent versus California who's at forty four percent. And when it comes to HIV prevalence rates, Santa Claus County is at one hundred and ninety nine versus California who's at four nineteen per one hundred thousand.

So that's why this work is really important for us to do education and outreach. We do have a communicable disease program which is committed to surveying the activities of communicable diseases to monitor, protect and prevent the spread of infectious diseases within our county. And so some of the services that they provide are surveillance and case investigation of all communicable diseases reported under Title 17. They provide disease outbreak response and management, contact identification and follow-up, and we provide coordination for prophylaxis, vaccinations and testing for the communicable diseases. So what that all translated into is that last year our team was able to test two ninety one people for syphilis, HIV, and hepatitis C at outreach events.

We also went out and supported response efforts for 74 communicable disease outbreaks to safeguard the community, which included 28 COVID-nineteen and 14 avian flu outbreaks. And then our staff also administered 6,322 vaccines to protect residents, and that's not including some of the vaccinations that our clinic division provides. Alright, so the next third bucket is policies, systems and environmental change. You're probably wondering what is that? So in public health we refer to that as strategies that improve health by making lasting changes to the conditions where people live, work, learn and play.

And just to give you an idea of our community metrics in Santa Claus County, we were at a thirty five percent when it comes to adult obesity compared to California at twenty eight percent, so it's a little bit higher. For physical inactivity, Santa Claus County is twenty six percent versus California which is at twenty two percent. And for adult smoking, Santa Claus County is at thirteen percent versus California which is at ten percent, so slightly higher there. Unfortunately, some of our funding, and this is important because unfortunately some of our funding was cut for our nutrition and physical activity work through HR1, which Heather will talk about a little bit later. But we're still continuing to provide some benefits to the community when it comes to policy systems and environmental change through some of our programming with WIC, oral health and tobacco.

So with that said, some of the highlights from last year in 2025 on average, WIC families redeem 84% of their monthly fruit and vegetable cash value benefit, and and some of that money went back into our community with the retailers. We supported local tobacco coalitions and local law enforcement in adopting two ordinances in the cities of Modesto and Siris to reduce reduce youth access to tobacco products. And we also strengthened school based oral health systems by screening over 500 students and identifying their urgent dental care needs in about ten percent of those students who may not have otherwise been screened. Right. And so lastly, the last bucket we have is strengthening community connection.

And this bucket really talks about our capacity building in community with our partners, because we, again, recognize that we can't do this all alone. And so one of our best strategies is to work with our community partners and increase their capacity to provide services as well. So some community metrics associated with some of the programming for this one are exclusive breastfeeding rates at three months. In Santa Fe's County we're at twenty seven percent, and in California it's thirty one percent, so we've got little ways to go to move that needle. And then when we look at children in poverty, Santa Claus County is at sixteen percent versus fifteen percent for California.

So with that said, some of the programming or highlights that we have is that we held 44 communicable disease trainings to strengthen workforce readiness. We also reached out to our partners in the sectors of healthcare and education and public health, and trained 25 staff through UC San Diego extension to become lactation education counselors to increase our capacity in the community to provide that support. And we also partnered with the Health Plan of San Joaquin First Five local FRCs or Family Resource Centers and also community partners to host the well received community baby showers, served 161 expecting mothers. So those were our programs in a nutshell. And I've said it a couple of times, we can't do any of this work without the help of our community partners, because those community metrics are really just metrics that we alone cannot move the needle on.

And so because of that, and with your help, on 11/05/2024, you, the Board of Supervisors, approved the Health Services Agency to establish the Health Initiative Unit. The unit was formally launched within public health last year in 2025 and it serves as the backbone structure for the coordination and infrastructure necessary to support the community health assessment as well as the community health improvement plan. So prior to that we didn't have any dedicated staff to do that. And since then with input from cross sector partners the unit subsequently developed the unified Stanco Health brand to represent a coordinated county wide approach to community health improvement. And so its tagline is strengthening partnerships and building community.

And you can see it there in that logo up there on the screen. So anytime you see Sanco Health you'll just know that that means that that is our community coming together to collaborate on moving the needle on those community metrics. So to advance this work, the Health Initiative Unit convenes the leadership council with, we have some board of supervisors who participate, as well as the Stanco Health Coalition. And the unit also facilitates action work groups which are focused on the three priority areas that are outlined in the community health improvement plan. And those are access to care, behavioral health, and chronic disease prevention and management.

So through cross sector partnerships, structured governance and data driven strategies, the unit promotes accountability and sustains system level progress to improve health outcomes across San Saucas County. And so those three pictures you'll see are on the screen are our latest coalition meetings and you can see partners around the table brainstorming about HR one impacts and other things or getting updates about HR one impacts. And we do offer Spanish interpretation for those who need it at our meetings as well. So with all of that work that's gone on in the last year since the unit has launched, I'm also happy to report a little preview for next year's report that the activities three in the community health improvement plan have already been funded, and so I'm very proud of the work that the Health Initiative Unit has already done in trying to move the needle. It's hard to do in talking to some of our other peers, getting some of those initiatives funded.

And so I'm proud that they were able to do that. And you'll hear more about that in next year's report as those activities continue. So with that said, I think we'll open it up for questions for Doctor. Papa and I.

Do we have any questions? Go ahead. Buck Buck, go ahead.

Buck. Yeah. Heather.

Heather, Elisha, doctor Papa, thank you for all the for the presentation and the information. That's great. And I have one question. The child mortality, do we have a breakdown of how the children passed? Trauma, accident, disease?

Yeah. So we did, yeah. So I have, we've looked at it, like, in terms of looking at this. It's not infant mortality, but it's for our children or age population in ages zero to 19. And there were four hundred eighty deaths in Stanislaus County for the time period 2019 through 2025.

And so some of those, some of the highest number were preterm birth complications. There were road injuries, neonatal conditions, congenital anomalies. So we do have we have that for, you know, for that larger age group, but not specifically for the infant age group. We did look at we didn't look at we looked at I would say we looked at data from, like, more limited data sets. I I think what we need to do now is break down go down specifically to our own death, look at that time frame from zero to one years old, the infant mortality, and try to really narrow it down for that group.

Thank you. And it was an honor to participate in the accreditation process. I think I was probably more nervous going in than you guys were.

For sure.

Thank you guys very much, doctor Papa, Alicia, and Heather for the presentation. You know, this is we get this once a year. This is depressing. It it always is depressing. It seems like we're always kinda behind when or worse off than the state and the nation.

And and I know you guys are doing all you can. Just in the report, I wish we could kind of have some more compares last year versus this year kind of stuff like that and I know there's a little bit of that but especially in in as Buck kind of referenced just a little bit, the children and families just mean, else can we do as a board? I mean, it is it a funding? Is it is it, you know, if we throw more money towards this, will that make a difference? Is there Anyway, I'm just wondering how do we move the needle more than the needle has been moving? I I've been here sixteen years and it is never We are always worse off than the state. We're all Again, I'm not blaming you guys for this, but we're always worse off than the state. We're always worse off than the nation. The only thing we're good in is suicides. I mean, that was great.

Their suicides are down and I and I credit to all the organizations that are working on that. I appreciate all the all the hard work that's going on with that. And the opioid coalition, I know, is doing everything they can to try to bring down the opioid deaths, overdose deaths. We're still getting higher than the rest of the state in that. And I know we have this, we've got the new, that we've put together most recently and we're hoping that's going to help with this stuff.

The, what we call it, our health initiative. Yeah, that's hopefully going to try to make a difference there. But I mean, tell us what else we can do. I mean, from your standpoint, I mean, what would you guys say? If we only had this, we could really make a difference here. Or is it I know I'm simplifying this. I get it. But anyway, that's my thought.

I think you hit the the nail on the head, supervisor Rithrow. I think what we can do is take this back to our, leadership council and take this back to STANCO Health and really do more brainstorming and then come back with a better ask about what we would do to reduce child mortality and infant mortality in Stanislaus County. So now that we have this unit formed, we can focus more on some of those activities because those are mostly unfunded activities.

Okay. That'd be great. Just because I know that would be welcomed from this board. We would do whatever we could. We'd find the funds. If that was it, if it was dollars that we're looking for, I mean, can't imagine a better investment than that. And so I mean, you guys are the experts and we trust what you're doing and very much appreciate what you're doing. But just come back and tell us what what do we need to fix this? To to get us so that that little line shows below what maybe the California average is or the national average is and that we've really made a change here in the community. Tell us what we need to do.

Thank you.

But thank you guys for the presentation.

Thank you.

Thanks. I'm gonna put a little more positive spin on it because I, for so many years, we were at arm's length with the health services agency, the public health officer, and then COVID hit. And now we've become much more cohesive and, you know, it took something bad for us to become so responsible. We do have an air quality problem based on, you know, because of our topography and that has a lot to do with lung issues and asthma rates and other things that that contribute. It keeps getting better, but the state is getting better, right?

So we're declining it at the same rate. So I think things are getting better. If you remember Doctor. Walker, our former public health officer, I know I've said this statistic many times, he says the easiest way to figure out the health of a newborn child is the educational attainment of the mother. And it makes so much sense, you know, it just correlates because you know to take your prenatal vitamins, know to exercise, not to smoke, all those things. And so we have higher incidents. We have a little less educated group of folks here. I mean, our graduation rates are lower than the state. So I think we've got this totality. There's so much that we can do, but there are other factors that we might not be able to control.

But we are much more cohesive and and working together now than we were five years ago, ten years ago for sure. So I see progress being made again as long as the trend line keeps going down. We're doing okay. Not great. Again, we can always do better, and I would agree with the supervisor's statements. Okay. No other board comments. I will now acknowledge that we don't have any written comments on this item. I'll open the public comment period. Does anyone in the audience wish to speak on this item?

Step forward. All right. Seeing none, I'm going to bring it back to the board. Move to approve. Motion to approve.

Second.

And a second. All All those in favor, aye. Aye. Opposed? Motion carries, five zero. Thank you very much. Appreciate your time and effort. All right. We're going to move on to discussion item number two, and that is the approval to accept an update on the House of Representatives' H. R.

One bill and its potential impacts to health and human services programs in Stanislaus County. Raul Christine Huber from Community Service Agency, Ruben Imperial from BHRS, and Heather Duvall from the Public Health Department, not Public Health, from the Health Services Agency. I'm confusing everything. Hi, Good

morning, Mr. Chair, members of the board, CEO Hayes, county council of Bose. I'm Raul Mendez, assistant executive officer, and I will be kicking off your staff presentation on this item, an overview of HR one, potential impacts to health and human services, or health and human service programs in Stanislaus County. I will be joined by members of our county organization. Christine Huber, our community service agency director.

Ruben Imperial, our behavioral health recovery services director. And as mentioned, Heather Duvall, our managing director of our health services agency. Also at the staff table, I have Kylie Kipp from our executive office, an executive assistant that'll be driving the PowerPoint. And so we have a lot of information to share, so let's go ahead and get started. So housing representatives one referred to as HR one is a federal law that was signed back on 07/04/2025.

It makes significant changes to Medi Cal, CalFresh, and work requirements. As the board is aware, these are considered critical safety net programs for counties centered around health coverage and also food assistance that many residents in our county rely on every single day. In preparation, Stanislaus County, like other counties across the state, have been working hard to better understand the significance of these impacts to our local programs and services that are currently provided to county residents. Today is the first of what we expect to be several conversations, public conversations on this topic as we move forward here in the next year. Since this is a statewide issue, the California Association of Counties or CSAC is working with counties across the state on a coordinated response to the HR one impact.

Counties are concerned about cost increases, coverage losses and workload impacts to county organizations. Your staff has been working with CSAC and partner affiliate associations to assess what those impacts mean to us here locally. This information compiled has helped inform a funding request that CSAC on behalf of all its counties submitted to the state last month. On April 7, Chairman Kiesa on behalf of the board and consistent with your adopted legislative platform, sent in a letter of support to CSAC's proposal. It went directly to the governor's office and also our other state representatives in each house.

The proposal or the budget request seeks $1,900,000,000 in the upcoming fiscal year twenty twenty six-twenty seven, and an additional $4,500,000,000 in fiscal year twenty seventwenty eight. This funding request is centered around county eligibility, county behavioral health, and indigent care and public hospital support. HR1 impacts or has effects to several of our county departments, some of which will be highlighted today including our community service agency, behavioral health and recovery services, and our health services agency and their operations and finances. And it also has the impact or potential impact to affecting other county departments. Significant cross department coordination will be required and your county departments have been meeting with our office to best position the organization to respond to these new requirements and obligations and the changes to existing programs and services as a result.

Before I turn it over to our department directors to provide potential impacts to the respective functional areas in greater detail, I believe it's important to zero in on who will be impacted in our county and how. As the board is aware many local residents rely on Medi Cal and CalFresh including vulnerable populations such as children, seniors, people with disabilities and working families. Nearly 90,000 Stanislaus County residents receive CalFresh. About 217,000 residents receive Medi Cal. New rules will require more work reporting and documentation as summarized on this slide.

At this time, I would like to turn over the presentation to Christine Huber from the Community Service Agency.

You, Jordi and Chairman Kiesa, Supervisors, Mr. Hayes and Mr. Bose. I'm here representing the community services agency which has the responsibility to determine eligibility for, these federal programs, specifically, CalFresh as we call it in California or SNAP or Medi Cal as as also we call in California or Medicaid at the federal level. So the first area we're going to focus on is CalFresh.

HR1 changes who qualifies for CalFresh based on someone's specific immigration status. In order to be eligible for federal CalFresh benefits, one must be a U. S. Citizen, a lawful permanent resident who has maintained status for five or more years, a Cuban or Haitian entrant, and individuals residing in The US under a compact of free association agreement. Those that have been currently receiving CalFresh but will no longer be eligible are asylees, refugees, immigration parolees, battered non citizen or traffic victims.

This begins in May 2026. So as somebody's renewal comes today, we will be assessing for their immigration status and at that time making determinations if they qualify or not. We are anticipating in Stanislaus County approximately 5,000 people to be affected by this federal change. The next area of impact is for people who are considered able-bodied adults without dependents. We refer to them as AVOD, which is the acronym.

Work requirements are being put back in place. California has had a waiver for many years for this requirement. And beginning in June 2026, CalFresh recipients who are between the ages of 18 to 64 with no children under the age of 14 either need to work in school or a training program or community service of activity of a minimum of eighty hours per month. This is somewhat changed from the previous regulations where it was from the ages of 18 to 54. There also were exemptions which were allowed for veterans, the unhoused, and former foster youth up to the age of 25 which are no longer going to be available.

If somebody does not meet this eighty hours per month of work requirements, they can receive the CalFresh benefits for three months in a thirty six month period. Through analysis, CSA believes that it will increase our workload an estimated four additional staff hours per newly impacted recipient. This begins in January 1 and will be evaluated at the customer's renewal month. We anticipate in California that approximately 39,000 people will be impacted by this. We are still researching and identifying how many we believe will have exemptions, but we don't have an exact number today for you.

The other area for CalFresh is basically costs that are being shifted to states and counties. And the first area has to do with administration funding. The federal government is shifting their administrative funding share from 50%, which is what it is today, to 25%. The states will be paying 52.5% of administrative funding and the shift at the local level is gonna shift from 15% to 22.5%. This will begin in 10/01/2026.

We estimate the shift in changes to the county will increase our cost by 2.1 to $2,700,000 annually. The other area that costs will shift to the county is around the payment error rate. So payment error rate consists of if we make a mistake in our assessing for eligibility. It also includes if a customer inadvertently makes a mistake in their reporting to us, as well as if a customer willfully commits welfare fraud. All of that is combined into our payment error rate.

If any state goes below a 6% error rate, they must contribute towards the benefit allotment. It's unknown how California will pass on the cost to counties. We know as a state we're in the 9% range right now. Right now, our air rate is being measured for the federal fiscal year twenty two thousand twenty eight when this goes into effect. So what we're doing now is going to affect what potentially California's air rate is.

The next area I wanna go into is Medi Cal eligibility. HR one does narrow the definition of a qualified non citizen similar to CalFresh for those who are federally funded through Medi Cal. So beginning 10/01/2026, those who can qualify are US citizens, again lawful permanent residents who have maintained status for five or more years, Cuban or Haitian entrants, and individuals residing in The US under a compact of free association. Those are very similar to CalFresh who are not eligible are refugees, asylees, immigrant parolees, battered non citizens, victim of human trafficking. We're anticipating that in Santa Claus County this is going to affect about 25,000 people.

The next area has to do with work requirements for Medi Cal recipients. This is specific to the Affordable Care Act adult expansion. So a little background. In March 2010 the federal government signed the Affordable Care Act. It was signed into law.

It took a few years to become available in the states. And so but what this did was expanded medical coverage to adults with no dependents who are between the ages of 19 to 54. And they also would have to have an income level under 138 of the federal poverty limit. This gave people access to health care that traditionally had not had it. So what this now is doing is that for that same population it requires recipients nineteen to sixty four years to engage in qualifying activities which would be working, going to school, in a training program, volunteering for eighty hours a month.

And there could potentially be exemptions. The one of the things about this work is that the federal government has not issued guidelines yet for this program. California has developed guidelines and a list of potential exemptions, but that is all still being finalized. One of the things is if there's a new applicant who's applying for Medi Cal, who's in this category, they must be meeting those work requirements prior to being approved. We anticipate this will be about three point five additional hours per client per year.

And we're anticipating about 71,000 residents that fall under this category. One other area for new applicants, for all of our new Medi Cal applicants is currently if you were to apply for Medi Cal today it would go back three months and pay for any appropriate costs that somebody might have encountered. And this is changing to one month if someone's 19 64 with no disabilities, and it will be going back look back, will be two months for a child, someone 65 years and older, those with disabilities. The next area is around semi annual renewals. For those in the affordable care adult expansion population, their renewals are gonna go from being once every twelve months to once every six months.

California is working to increase automation in both this in the renewal area and in the previous one around work hours and requirements. So, hopefully, this will help have an impact on the workload, but the workload is still expected to increase an additional one point two hours per renewal. And again, it's the same population as the previous, so approximately 71,000 people will be impacted by this. The last area just wanted to call your attention to is the impact to the customer or our clients that live in Stanislaus County. Beginning July 1, twenty twenty seven adults with considered unsatisfactory immigration status will be required to pay a $30 premium per member.

This is a California state laws change. This is not part of HR one, but we wanted to point that out as a, you know, an impact to the to the resident.

Christine, explain unsatisfactory immigration status.

So those would be most of the categories that were referenced before. So those that are not US citizens that are not

So that's just the terminology the state's using? Yes. Okay, perfect. Thank you.

And then also beginning 01/01/2028, states are required to implement a cost sharing for adults without children whose income is above the 100% of the federal poverty level. It's up to the state how much they charge, but they can charge a co pay of up to $35 per service. These are this that's implement since it's implemented in 2028, the the state's still developing policies and for us also to understand the impacts, we're still researching them.

Can I just one more question? So all all of these stats with regard to, Stanislaus County, how how we're impacted, the number of individuals will be impacted are before the exemptions that are out there that we just don't understand what the exemptions are yet. Sounds like the state has exemptions that they've come up with but we are still looking at those or those aren't finalized it sounds like. So And we can't count on those. So am I understanding that right Christine that all these numbers as far as impacts the Sands case. So once we have more formal or finalized guidelines with regard to exemptions then we can revise these numbers and how many are gonna actually be impacted in the county?

That is correct, supervisor Withrow. The the intent today was to kinda lay everything out as we know it today and have it coming back as needed to update information, update the board of

the committee. Okay. Very good. Thank you. Thanks, Christine.

And I'm going to turn it over to Ruben Imperial from Behavioral Health and Recovery Services.

So the analysis that we provided as part of the staff report today is rooted in the California Behavioral Health Directors Association analysis of the impact statewide. And what we did is we extrapolated that data locally. So a few things before I go over the numbers is that the county is the Medi Cal behavioral health plan, so we basically act as the insurance provider for behavioral health services for the Medi Cal beneficiaries in our county. And as part of that plan role, a large percentage of our services are funded with Medi Cal revenue. And the way we conduct we develop our budgets is we get a certain amount of state revenue through various forms such as realignment, Behavioral Health Services Act, and we develop our budgets as such where those funds then also rely on drawing down Medi Cal revenue.

Requires that the individuals in these treatment programs are Medi Cal beneficiaries, and that is our primary population that we do serve. So, with less individuals covered under Medi Cal or losing coverage in the course of that treatment, there are instances and at times in the process where if these, as these new HR1 policies roll out, will have an impact on overall Medi Cal revenue for the department. So the early estimates, and again, these are based on a statewide analysis, and again, costing those numbers out locally within the fiscal year 2027, which is the one coming up, we would have about a $2,300,000 Medi Cal revenue loss. And that's primarily because these impacts or the implementation of HR one, a lot of these start in the fall of this year, so we would not see a full year of these impacts at BHRS. Once all these HR1 policies are rolled out, we do anticipate that there would be an overall $12,000,000 total treatment cost impact annually, which is in the range of about 4% to 6% of our overall budget.

That $12,000,000 though, does represent the total cost of programs. The Medi Cal revenue drawn down in a $12,000,000 treatment budget like that would probably be about half of that would be the Medi Cal revenue we would lose. So these are, these are again, early, early projections, trying

to

get trying to get some clarity for departments like ours to begin planning and to work through how this would look for us. Supervisor Withrow, you rightfully stated that there are still some exemptions that are under analysis and review and are moving towards for implementation. We're getting more information, you know, every week. And for the behavioral health population with serious mental illness and substance use disorder, Right now there are some exemptions for this population, especially around renewals and work exceptions. So we are looking forward to having our updated analysis once those policies are finalized.

I'm going to pass it over now to my colleague Heather DeVaugh.

Good morning again. So as we look to the health services agency and possible impacts, there are three areas that I want to speak about today. One is specific to our HSA clinics and ancillary services. For our clinic system, as you well know, a large percentage of our population are Medi Cal recipients and it's ninety percent. And so as we see the numbers of people in Medi Cal overarching throughout the state and the county decrease, there will be fewer reimbursable visits and increased uncompensated care coming to our clinics.

We've already begun to see a little bit of a decline from January to March. We're looking at about 7% fewer Medi Cal patients assigned to us from the two health plans. We've got ongoing work to assess this fiscal impact. We're working closely with HMI consultants on this and also what I'll be speaking about with the medically indigent program in just a second. Specific to public health, Eylecia Sanders also kind of shared a little bit about this already, but the SNAP Ed, or known here in California, CalFresh Healthy Living Program, ended with HR1, and that was really work around nutrition education prevention in our community.

This was four full time equivalent staff that were lost doing this work out in the community, working with vulnerable populations around how to eat better and be more active. We had a fairly decent contract with SCO, County Office of Ed, with our Harvest of the Month program and things like that, that have also come to an end. And as we were working, a supervisor with Throw, you mentioned about, you know, we're doing worse. And these are the type of programs that are really looking at heart disease and things like that, that were obesity prevention. It's kind of one of those end of an era.

I returned to the county working part time when this program kicked off, so it's really a of hard work there. Next, we'll look at the Indigent Health Care Program, which is absolutely the greatest impact. Under California code, welfare and institution code, each county is responsible and legally required to provide care for medically indigent residents. This can be each county has a little bit of autonomy there on how they want to develop this program and what it looks like. San Luis County provided, this obligation through the Indigent Healthcare Program.

As the program was going, we served approximately 7,800 residents per year with an annual budget of 14,000,000 and fifty five staff working in this. They did eligibility determination, enrollment, provider network management, utilization review, claims processing, care coordination. And the primary care was provided through the HSA clinics as well as specialty care at that time. As Christine explained really carefully and well was the Medi Cal expanded population. And so as that fell into full implementation in 2024, we saw a significant and now no people enrolled in an indigent healthcare program.

So what happened is folks went on, were able to access Medi Cal or cover California. They and the and we call it the IHCP program. The operations became inactive. However, the legal mandate still is remained. This health care is provided by funding from realignment, which is sales tax as well as vehicle license fees.

And AB 85 resulted in those dollars, those realignment dollars, being redirected back to the state because the state said, Well, you're not serving Indigent Health folks any longer, and so we're pulling these dollars back. So there's no longer a specific spending spring for this work. So where we are now is we've spent a lot of time with our consultants trying to look at what this might look like. There's a lot of variables. We're looking at eligibility, how many people will be exempt, what are those projections, what might this look like.

Also what might reestablishing the IHCP program, what that might look like for the health services agency. We will need to review eligibility criteria specific to the newly impacted populations, develop provider care networks, we need to do contracts with hospitals and specialty care. We will have to develop a system. We had a very old system that is no longer operational that looks like procurement that we'll have to procure for eligibility, utilization and claims management and restaff up for staffing and administrative structure. The estimated costs that we have are really, as my colleagues have said, these are certainly estimates, right?

If we were to restart our current IHCP program the way it stands right now, The start up, what we're looking for the first year, which is only a six month period in fiscal year twenty twenty seven because of the timing of the impacts, we're looking at $12,000,000 going to 20,000,000 in fiscal year twenty twenty eight and 34,000,000 in fiscal year twenty twenty nine. We do have the ability to, the IACP program requires for very, very basic health care. That's not what our current program offers. We did the minimum required program. It would be 8,000,000 in fiscal year twenty twenty seven, 11 in 2028, and 18,000,000 in fiscal year twenty twenty nine. And again, as I said, just really wanna reiterate, these are big estimates at this time.

Is that Heather, sorry, again. Yeah. Is that the for this we estimate 7,800 residents would fit into this category, Indigent Healthcare Program.

Potentially. Okay. A lot of play there depending on the work requirements, what's met, what exemptions are, and how this board wants to look at eligibility.

And so before we had an annual budget of 14,000,000 for that, right, was that before the program, before these individuals didn't qualify for this anymore, right? They weren't our responsibility anymore.

So, right, we had the realignment dollars that were specific for that, and that got redirected.

Mhmm. So so so now it's now we're saying for those some same 7,800 residents, it could be as much as 34,000,000, you think, in 2029?

Yes. With increase in health care costs and and things like that. Yes.

And so

were never relieved to have that responsibility. People just converted from the medical imaging program.

To the Yeah.

Yeah. Thank you.

Okay. Thank you. You're welcome.

Thank you, Heather. So I'm gonna try and kinda summarize what you've been presented this morning and starting with what does this all mean for county residents. So we are talking about residents may face loss of benefits and increase administrative burden. That said the need for the services, even if coverage decrease remains. So I think that this slide kind of just summarizes what the resident should be tracking.

Next slide please. What does this mean for the county or for Stanislaus County? County will obviously face higher costs as indicated by some of the detail provided by our departments. Workloads and demand pressures. Our indigent healthcare program could require multi million dollar funding at levels above, significantly above what was previously the level when the county had these programs in place.

Over time and as clear guidance is provided by the state, the county will need to make policy decisions regarding our safety net programs that will be impacted by HRR1. You saw Heather cover the costs. They're highlighted there on the slide for your reference. Critical next step as we look into the May revise, the governor's May revise here in a few weeks now. We are hopeful that there'll be additional details that will help us evaluate what we can expect here locally.

Hoping that there's clarity around state funding levels, our county cost responsibilities, any administrative funding support that may be available, and then program implementation details as noted. The exemption information will be helpful as we continue to evaluate these impacts here locally. As mentioned to supervisor Withrow, your staff will return back after the May revise once we have had an opportunity to review the information that it contains, to refine our estimates, present additional data. And we will likely do that over the course of the next few months, likely by individual program just for simplicity. We felt it was important for this first presentation to be as all encompassing as it could be.

If there's other county departments that we anticipate impacts to we will try to bring those forward in future presentations. So this concludes staff's presentation on this topic for this morning. The team is open for additional questions before we ask that you accept this first report on the potential impacts of HR one to Stanislaus County Health and Human Service programs. Mister chair, back back to you, sir.

I'm doing my math. Okay. Any questions of staff?

Comments? Just quick comments. Thank you guys so much. And I know this is a lot of work trying to figure out where this is going and what it's going to cost and how it's gonna impact our our citizenship. But I appreciate all of the work you guys are doing to to figure this stuff out.

It seems like the and this is just the obvious, but just the the bigger thing that and I think this kind of came up really back when when back during the government shutdown when we figured out all these people weren't, how how many people were gonna be affected by it and on the food program, the CalFresh, think probably, and it's just amazing how many, you know, when I look, we look at the 90,000 residents here, you know, almost a quarter of our, you know, less than a quarter of 20% of our population is dependent on these things. The big and 217,000 of them are on Medi Cal, almost half. Shoot. So, I mean, the bigger thing is, yeah, we're gonna deal with this and figure out what we have to do and what it's gonna cost us and figure out where the money's gonna come from. But it seems like the bigger thing is that and and we always and we're always working on this, is how do we get these people not dependent on CalFresh and not dependent on Medi Cal?

You know, how do we just lift everybody up so that these programs aren't required anymore? And so, again, that's just looking at it from a 30,000 feet to really solve our problems so that we're not in this spot and our and our citizenship aren't aren't people in our community aren't in it as as we've got. And I know we work on that constantly. We're constantly trying to figure out how to make everybody in a better spot, get everybody in a better spot through all kinds of programs we have. But that's the most discouraging part about this is that we still have so many people that are dependent on these things.

And how can we direct our resources towards getting them out of that's not it's easy to say that. I I get it. But I think that's what we need to continue to focus on. As we focus on this right now, it just kind of really points out and highlights how we really need to continue to to work to where these numbers get down so low when something like this happens that we're, it's not affecting so many people. Okay. I'll shut up. Thank you, guys. Thank you.

And so I I have a comment. It's a question, but I wouldn't expect anyone to answer it today. We have different it was Christine, some of the statistics you put on how many people potentially are affected, and it just shows you the unclarity. We're a percent and half of the population in Stanislaus County Of California. One of the programs, it shows about four percent of our folks are potentially at risk.

Another one shows seven percent. And then the big one is the narrowing of the definition of a qualified non citizen. It shows up to twelve point five percent, which seems high just on face value. But again, that's the uncertainty of which we're dealing with. CSAC, this has been the number one priority.

They've been walking the halls. The last two times I've been in Sacramento, they're working hard because they view the first component is the compassionate side and then there's also the unfunded mandate side of taking the money from the medically indigent program because the people had migrated off of that into the what's the program in California? California, the exchange. Covered California. There we go.

Then migrated off, so they swiped the money, which seems completely legitimate. And so now if they come back onto our roles and become our responsibilities, that funding, the same cost of the program as would have been had there not been an exchange, should be given back to us. The concerning part is that there's additional work being put on departments regardless of when you go in. That will be an unfunded mandate that needs to be addressed that their CSAC is trying to deal with and the May revise. So there but just the uncertainty around everything until all the rules are written and we we can go through, it's very hard for us to say what our need is because we, again, until you ask the question of the folks, you're not going to have the answer of where we need to be.

And so, all right. With that, if there's no other comments here, I'm going to acknowledge there are no written comments on this. Also, we're going to go ahead and open the public comment period. Does anyone in the audience wish to speak on this item? Please come forward.

Thank you, Mr. Chairman, Supervisors, Mr. Hayes and Mr. Bose. I was scratching some notes as I was listening to the presentation. First off, Supervisor Withrow, I'm 100% behind you. If we could figure out a way to get all of these impacted folks off these programs, we would all be better off as a county. So but that's definitely a long term impact that we have to work on. But when I totaled the number of people, it came up to 212,000. Now we know that there are many of those who are double counted in or are going to be double counted in various categories, but that's a lot of people that are going to be impacted but they all share one thing in common they don't make campaign contributions.

I'll come back to that. We also know that the state is still going through its 57 varieties of budgets that they'll go through before they come up with the final one and that's going to impact what we have to do. Bottom line is that we as a local agency, local as our county, we're going have to make some very, very, very brutal decisions on who's going to be impacted and how we're going to take care of these folks. But at the same time, the federal government passed H. R.

One which inflates our debt by well over a trillion dollars, provides billions of dollars of tax breaks for wealthy individuals who do make campaign contributions excuse me, contributions and we're stuck having to take care of our local people because even though the federal government can spend recklessly, we can't. We have to balance the budget. So that's a tough position that we're in as a county. It's a very tough position for you as the supervisors who have to make that decision and there is no easy answer. So and I wish I could offer a magic solution but I'm very much as lost as Mr.

Withrow on how to solve this problem. So all I can say is please think carefully on what we can do and once we have the numbers from the state, let's just try to do the best we can to mitigate the impact for everybody involved. Thank you very much.

Thank you for your comments, Steven. Anyone else? I will add, I know, Heather, you talked about realignment covering a component realignment comes through sales tax and then sometimes the growth in the program. The program growth exceeds the amount of money and that's when we start shoveling general fund discretionary spending into programs. And so there are certain components of this that will impact the community but won't impact discretionary spending, and there are other components that will have a profound effect.

And those are the ones that probably are nearest and dearest to the public in general, where we spend those dollars, the discretionary dollars. So it could have a real profound impact. All right. Seeing no one else from the public, I'm going to close the public hearing. And public comment. I'm sorry, I

say public hearing, public comment. Bring it back to the board. Thoughts? Last thoughts?

Okay. Action.

Let's make a motion to approve the report. Accept the report. Thank you, guys.

Thank you. Second.

Motion is second. Thank you all for that update. Look forward to more updates sooner rather than later. Okay. All those in favor say aye. Aye. Opposed? Motion carries. Five, zero. Thank you. Okay, on to correspondence. Acknowledge receipt of correspondence and refer as recommended on the agenda. Any Board of Supervisor reports? None. On to item 10, legislative fiscal management report, CEO Hayes.

Sorry, was just trying to get my microphone here. I did want to announce that our health services agency in partnership with the United Way associate their annual Strong Together Conference, that's May 20 at the Doubletree. So please help yourself to an event flyer on your way out today or you can request a complimentary event registration by emailing strongertogetherunited, I'm sorry, uwaystan dot org. You can contact our office if any of that is confusing as well. Thank you.

Okay.

We do have a, oh, yeah. Thank you. Thank you. Before I close the meeting today and we go go on because I've forgotten the last couple of weeks, Deputy Trevino, thank you so much, as always, for keeping us safe.

Yes. We have closed session this morning. Existing litigation pursuant to government code section five four nine five six point nine subdivision d one one case. I can't speak. Salvin Singh versus Valley twenty nine Electric LLC. Chase Homan Kunha at at that's a and County Stanislaus et al. That's in the Stanislaus County Superior Court, and the case number is CV25001082. Appropriate for public comment.

Any public comment on the closed session? Seeing none, we will adjourn to closed session.