UNFINISHED BUSINESS  

Bill No: SB 228

Author: Jackson (D), et al.

Amended: 9/3/19

Vote: 21

SENATE HUMAN SERVICES COMMITTEE: 6-0, 4/22/19

AYES: Hurtado, Stone, Beall, Jackson, Pan, Wiener

SENATE APPROPRIATIONS COMMITTEE: 6-0, 5/16/19

AYES: Portantino, Bates, Bradford, Hill, Jones, Wieckowski

SENATE FLOOR: 38-0, 5/23/19

AYES: Allen, Archuleta, Atkins, Bates, Beall, Borgeas, Bradford, Caballero, Chang, Dodd, Durazo, Galgiani, Glazer, Grove, Hertzberg, Hill, Hueso, Hurtado, Jackson, Jones, Leyva, McGuire, Mitchell, Monning, Moorlach, Morrell, Nielsen, Pan, Portantino, Roth, Rubio, Skinner, Stern, Stone, Umberg, Wieckowski, Wiener, Wilk

ASSEMBLY FLOOR: 79-0, 9/9/19 - See last page for vote

SUBJECT: Master Plan on Aging

SOURCE: Author

DIGEST:

This bill requires the Secretary of the California Health and Human Services (CHHS) Agency to lead the development and implementation of the Master Plan for Aging, as specified. This bill requires the Secretary to work with specified agencies to identify policies, efficiencies, and strategies necessary to implement the Master Plan, as specified. This bill also requires reports to be submitted to the Governor and the Legislature by October 1, 2020, and annual updates thereafter, until October 1, 2030, regarding the Master Plan.

Assembly Amendments

strike the development of a No Wrong Door System plan and universal tool and instead require the Master Plan for Aging to consider the efficacy of utilizing a No Wrong Door System and the efficacy of using a universal tool. They also refine the activities required around the development and implementation of the Master Plan for Aging.

ANALYSIS:

Existing federal law:

1. Establishes, in federal law, the Older Americans Act, which promotes the well-being of Americans 60 years of age and older through services and programs designed to meet the specific needs of older citizens. Services provided under the Older Americans Act include home-delivered and communal meals; family caregiver support; health services home assistance for the elderly; job training and volunteer opportunities; and protections from elder abuse (42 U.S. Code 3001, et seq.)
2. Establishes Medicare, a federal health insurance program for aged and disabled people. (42 USC 1395 et seq.)
3. Establishes the Medicaid program, under which health care services are provided to qualified, low-income persons. (42 USC 1396 et seq.)

Existing state law:

1. Establishes the Mello-Granlund Older Californians Act, which establishes the California Department of Aging (CDA), and sets forth its duties and powers, including, among other things, entering into a contract for the development of information and materials to educate Californians on the concept of “aging in place.” (WIC 9100 et seq.)
2. Establishes the Medi-Cal program, which is California’s Medicaid, to provide various health and long-term services to low-income women, parents and caretaker adults, children, elderly, people with disabilities and, under the Affordable Care Act, adults without children or who are not pregnant between the ages of 19 and 65. (WIC 1400 et seq.)
3. Establishes the In-Home Supportive Services (IHSS) program to provide supportive services for aged, blind, or disabled persons who are unable to perform the tasks themselves and who cannot safely remain in their homes unless such services are provided. Those supportive services include, but are not limited to, domestic services, heavy cleaning, personal care services, and accompaniment during travel to health-related appointments or to alternative resource sites, yard hazard abatement, protective supervision, and paramedical services, as defined. (WIC 12300 et seq.)

This bill:

1. Requires the Secretary of CHHS to, in coordination with the Director of CDA, lead the development and implementation of the Master Plan established pursuant to Executive Order N-14-19.
2. Requires the Master Plan for Aging Stakeholder Advisory Committee established pursuant to Executive Order N-14-19 to include representation from older Californians, adults with disabilities, local government, health care providers, health plans, employers, community-based organizations, foundations, academic researchers, and organized labor.
3. Requires the Secretary and the Director of CDA, with the assistance of a workgroup established pursuant to the executive order, to work with specified agencies, as needed, to identify policies, efficiencies, and strategies necessary to implement the Master Plan.
4. Requires the workgroup to solicit input and gather information to assist with the implementation of the Master Plan.
5. Requires that the Master Plan be centered on specified core values.
6. Requires CDA to submit a report to the Governor and the Legislature by October 1, 2020, and submit updates annually thereafter, until October 1, 2030, regarding the Master Plan, as specified.

Background

According to the author, “The fundamental problem that SB 228 tries to address is a lack of planning for an aging population.” One thousand people turn 65 every day in California, and more than 20 percent of the state’s population will be age 65 or older by the year 2030. “We have so much to do between now and 2030 to get ready for the coming wave of older Californians. It isn’t enough to build accessible, affordable housing. It isn’t enough to train as many as 500,000 more healthcare workers. We also need to bring a new perspective to the challenges facing seniors and innovative solutions to the problems we’ve faced for generations. We want robust communities, housing choices, and readily available health care. We need to look at the obstacles comprehensively. That is what SB 228 seeks to do – provide a framework for state and local officials to look at and address the challenges facing California and its older citizens,” the author states.

Aging Demographics

In California, the senior population is projected to increase by four million in the next 10 years. In 40 years, California’s Department of Finance projects California’s senior population will grow to approximately 13.5 million. According to AARP, California’s age 85 and older population will grow 243 percent from 2015 to 2050 and the state’s age 65 and older population will increase 119 percent.

Causes of the projected rapid growth of senior population include aging baby boomers and increasing longevity, in general. With longevity comes increased need for care. This indicates higher number of individuals with chronic conditions associated with aging and increasing cost of the care they need. AARP’s Public Policy Institute has found that 87 percent of adults age 65 and older want to stay in their current home and community as they age. Seventy percent of people over 65 will need assistance with performing activities of daily living in order to continue living in their homes.

Long Term Services and Supports (LTSS)

LTSS are the services and supports used by individuals of all ages with functional limitations and chronic illnesses who need assistance to perform routine activities of daily living such as bathing, dressing, preparing meals, and administering medications. LTSS include the wide array of medical and non-medical services provided to people of all ages with impaired mobility, impaired cognitive function, physical or mental disabilities, complex medical needs or chronic disease. Individuals may need these services on a regular or occasional basis, for a few months or a lifetime.

LTSS include personal care services; assistance with health maintenance; assistance with activities of daily living such as bathing, dressing, toileting, and cooking; adult day services; transportation; social services; in-home support care; assisted living; assistive technology; nutrition assistance; person-centered care coordination; and nursing facility services.

LTSS can be home based care, which is provided by personal care aides, home health aides, and caregivers. They can also be provided in community based settings, such as assisted living facilities, adult day care, respite care, senior centers and meal programs. Additionally, LTSS may occur as facility based care provided in nursing homes, intermediate care facilities, and other 24-hour care settings.

Approximately 20 percent of the people who need LTSS live in an institutional setting. The remaining 80 percent living in the community primarily reside in private homes and residential care facilities for the elderly. For those living at home, most receive assistance from unpaid family and friends (referred to as informal caregivers), some pay out of pocket for assistance, and low-income households may qualify for Medicaid (Medi-Cal in California) services such as via the IHSS program.

Complex System of Long-Term Care (LTC)

California's LTC system is made up of numerous programs at the state, regional, and local levels. In many communities, multiple agencies administer LTSS and have complex and duplicative intake, assessment, and eligibility functions. This can create a lack of access to coordinated services and cause consumers and their families to struggle with identifying and accessing necessary home and community-based services. Going without these services can increase the likelihood of hospitalization and institutional placements.

Multiple reports have called for systemic change in the state’s LTC system to address the socioeconomic needs and demands of our growing and increasingly diverse older adult population. According to a report by the Senate Select Committee on Aging and Long Term Care, A Shattered System: Envisioning and Implementing an IDEAL Long-Term Care System in California, “Reliance upon our existing patchwork of programs and services to serve our growing aging and disabled population will result in unnecessary expenditures, inequitable access, and irrelevant services. Furthermore, under the existing fragmented structure there is no leader to oversee or coordinate the entire range of services, and no mechanism for accountability or improvement.”

Master Plan on Aging

There are numerous efforts underway to address the growing need for a comprehensive statewide strategy to develop a person-centered, culturally appropriate long-term care system that would enable individuals to receive services in the most affordable, home-like settings available.

Recognizing the need for a comprehensive look at the system that supports older adults, Governor Newsom signed Executive Order N-14-19, which calls for the establishment of a Master Plan for Aging by October 1, 2020 that will “serve as a blueprint for state government, local government, private sector, and philanthropy to implement strategies and partnerships that promote healthy aging and prepare the state for the coming demographic changes.”

This executive order directs the Secretary of CHHS to convene a Cabinet-level Workgroup for Aging to advise the Secretary in developing and issuing the Master Plan. It also directs the Agency to convene a Stakeholder Advisory Committee that will include a broad range of Californians with an interest in building an age-friendly California.

The Executive Order notes that, “all older adults, and those with disabilities, should be able to choose to remain in their communities as they age,” and that “meaningful choice requires access to a broad range of public and private programs, resources, and supports, including health, homecare, food and nutrition, humans services, housing and transportation.”

This bill builds on the executive order by mandating the Secretary of CHHS to lead the development and implementation of the Master Plan and requiring ongoing reporting to the Legislature on implementation of the plan. These reports are required to identify any statutory and regulatory changes necessary to implement the plan; status of implementation of the plan; as well as data metrics, best practices and model policies.

Related/Prior Legislation

SB 70 (Committee on Budget and Fiscal Review, Chapter 27, Statutes of 2019) required CDA to administer a grant program for the purpose of implementing a No Wrong Door system, if certain conditions are met. Grants would be awarded to qualified Area Agencies on Aging and Independent Living Centers. The Budget Act included $5 million ongoing for this purpose.

SB 453 (Hurtado, 2019) requires CDA, in consultation with the ADRC Advisory Committee, to develop a core model of best practices by July 1, 2021, which ADRC programs will then be required to implement by July 1, 2022. The bill also creates the ADRC Infrastructure Grants Program. The bill also requires CDA to take specified actions regarding the implementation of a No Wrong Door System.

AB 1287 (Nazarian, 2019) requires the Master Plan for Aging, developed pursuant to Executive Order N-14-19, to consider the efficacy of utilizing a No Wrong Door System for assessing older adults, people with disabilities, and caregivers in obtaining information and referrals to services and supports. The bill also requires consideration of a universal tool and process that is capable of assessing individual need and determining initial eligibility for LTSS.

SB 1036 (Committee on Budget and Fiscal Review, Chapter 45, Statutes of 2012) required the CDSS and CDA to convene a stakeholder workgroup to develop a universal assessment tool for specified home- and community-based services.

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: No

According to the Assembly Appropriations Committee, this bill will likely generate unknown potential cost pressure to implement any No Wrong Door System or universal tool concepts that were considered by the Master Plan for Aging. Costs will depend on the actual recommendations implemented.

SUPPORT: (Verified 9/9/19)

Alzheimer's Association

California Assisted Living Association

California Association for Health Services at Home

California Association of Area Agencies on Aging

California Association of Public Authorities for IHSS

California Collaborative for Long-Term Services and Supports

California Commission on Aging

California School Employees Association

California State Association of Counties

Californiahealth+ Advocates

CalPACE

County of Santa Clara

LeadingAge California

National Association of Social Workers, California Chapter

San Diego Regional Chamber of Commerce

State Independent Living Council

UDW/AFSCME Local 3930

OPPOSITION: (Verified 9/9/19)

None received

ASSEMBLY FLOOR: 79-0, 9/9/19

AYES: Aguiar-Curry, Arambula, Bauer-Kahan, Berman, Bigelow, Bloom, Boerner Horvath, Bonta, Brough, Burke, Calderon, Carrillo, Cervantes, Chau, Chen, Chiu, Choi, Chu, Cooley, Cooper, Cunningham, Daly, Diep, Eggman, Flora, Fong, Frazier, Friedman, Gabriel, Gallagher, Cristina Garcia, Eduardo Garcia, Gipson, Gloria, Gonzalez, Gray, Grayson, Holden, Irwin, Jones-Sawyer, Kalra, Kamlager-Dove, Kiley, Lackey, Levine, Limón, Low, Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin, Muratsuchi, Nazarian, Obernolte, O'Donnell, Patterson, Petrie-Norris, Quirk, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Salas, Santiago, Smith, Mark Stone, Ting, Voepel, Waldron, Weber, Wicks, Wood, Rendon

Prepared by: Taryn Smith / HUMAN S. /

9/9/19 22:52:04

**** END ****

SENATE THIRD READING

STR Bill Id:SB 228

Author:(Jackson)

As Amended Ver:September 3, 2019

Majority vote

SUMMARY:

Requires the Secretary of the Health and Human Services Agency in coordination with the Director of the Department of Aging to lead the development and implementation of the Master Plan for Aging, established pursuant to Executive Order N-14-19.

Major Provisions

1. Requires the Secretary of the Health and Human Services Agency to lead the development and implementation of the Master Plan for Aging, established pursuant to Executive Order N-14-19.
2. Requires the Secretary and Director to work with both the Stakeholder Advisory Committee and the Cabinet Workgroup for Aging.
3. Specifies composition of the Stakeholder Advisory Committee and the Cabinet Workgroup.
4. Specifies the core values to guide the Master Plan including the concepts of equity, addressing the needs of individuals who are aging and those with disabilities; to be person-centered; seek efficiency by reducing duplication and unnecessary costs; achieve system rebalancing by prioritizing home- and community-based services provided in a home setting as alternatives to institutionalization, in accordance with individual needs, desires, and preferences; seek coordination and integration by integrating systems of care; and achieve access to long-term services and supports.
5. Requires the Department of Aging to report to the Legislature and the Governor by October 1, 2020, on necessary improvements to the department to effectively implement, and to identify the statutory and regulatory changes necessary to implement the Master Plan.
6. Requires the department to submit annual status updates from October 2021 through October 2030, including updates regarding data metrics, best practices, and model policies.

COMMENTS:

There is substantial energy and focus among stakeholders, the Governor, and Members of the Legislature to convene a discussion around the needs of California's older adults and people with disabilities. With substantial participation of the Legislature and the Governor's Administration and stakeholders, there can be a robust process culminating in a report by October 1, 2020.

According to the Author:

"Without adequate services and planning, many of our state's older adults face a risk of becoming homeless or losing access to essential care. We cannot afford to leave our aging adults behind. California must step up and prepare for this rapidly growing population. Twenty percent of California's older adults live in poverty, and this number is expected to increase with the aging of the state."

Arguments in Support:

"The Alzheimer's Association commends Senator Jackson and Governor Newsom for spearheading a Master Plan on Aging….Together, the Legislature and the Administration can strategically plan and thoughtfully prepare to embrace historic demographic shift on the near horizon."

Arguments in Opposition:

None.

FISCAL COMMENTS:

According to the Assembly Appropriations Committee:

1. Unknown costs, likely in the high-hundreds of thousands of dollars (General Fund).
2. Unknown costs (various funds) to other specified agencies for additional workload necessary to serve on the task force.
3. Unknown potentially significant future cost pressures to implement the recommendations of the task force and provide the required updates.

VOTES:

SENATE FLOOR: 38-0-0

YES: Allen, Archuleta, Atkins, Bates, Beall, Borgeas, Bradford, Caballero, Chang, Dodd, Durazo, Galgiani, Glazer, Grove, Hertzberg, Hill, Hueso, Hurtado, Jackson, Jones, Leyva, McGuire, Mitchell, Monning, Moorlach, Morrell, Nielsen, Pan, Portantino, Roth, Rubio, Skinner, Stern, Stone, Umberg, Wieckowski, Wiener, Wilk

ASM AGING AND LONG-TERM CARE: 7-0-0

YES: Nazarian, Voepel, Boerner Horvath, Kalra, Lackey, Reyes, Blanca Rubio

ASM HUMAN SERVICES: 8-0-0

YES: Reyes, Mathis, Arambula, Choi, Friedman, Gipson, Maienschein, Mark Stone

ASM APPROPRIATIONS: 18-0-0

YES: Gonzalez, Bigelow, Bloom, Bonta, Brough, Calderon, Carrillo, Chau, Diep, Eggman, Fong, Gabriel, Eduardo Garcia, Maienschein, Obernolte, Petrie-Norris, Quirk, Robert Rivas

UPDATED:

VERSION: September 3, 2019

CONSULTANT: Gail Gronert / AGING & L.T.C. / (916) 319-3990 FN: 0001630

Date of Hearing: July 10, 2019

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez, Chair

SBPCA Bill Id:SB 228

Author:(Jackson) – As Amended Ver:April 25, 2019

Urgency: No State Mandated Local Program: No Reimbursable: No

SUMMARY:

This bill requires the Governor to appoint a Master Plan Director (Director) and establishes an Aging Task Force to work with the Master Plan Director to develop the Master Plan for Aging that meets a number of specified criteria. Among the bill’s major provisions:

1. Requires the Governor to appoint a Director who has experience working in the field of aging or long-term care to the lead the master plan process.
2. Creates an Aging Task Force consisting of 13 members, with appointments by the Governor, the President Pro Tem of the Senate and the Speaker of the Assembly.
3. Requires the Director, with the assistance of the task force, to work with impacted state departments, stakeholders and any other appropriate agencies, to identify policies needing implementation to prepare for the aging of California’s population.
4. Requires the task force to ensure that the master plan is focused on specified core values.
5. Requires the Director, by July 1, 2021, to oversee the completion of an environment survey analysis of existing program capacity, with the information obtained mapped county-by-county and made available on-line.
6. Requires the task force to develop an implementation process describing strategies, accountabilities, deliverables and timeframes necessary for achieving the master plan’s goals and to measure and evaluate progress towards those goals.
7. Requires the master plan to include a fiscal plan and timeline for building long-term services and supports infrastructure, prioritizing areas where unmet need is the most acute.
8. Requires, by January 1, 2021, the Chancellor of the Community Colleges and California State University to develop, and requests the President of the University of California to develop, a strategy and fiscal plan to ensure the availability of a culturally competent workforce to meet the needs of an aging population by 2030.

FISCAL EFFECT:

1. Unknown costs, likely in the mid- to high-hundreds of thousands of dollars (GF) for salary, operating expenses, equipment and support staff for the Director.
2. Unknown costs, likely in the mid-hundreds of thousands of dollars (GF), for an unspecified state agency to establish and administer the task force. This would include consulting services and state staff support to provide research and administrative support to the task force.
3. Unknown, potentially significant costs (GF) to the Community Colleges and the California State University to research and develop a workforce strategy and fiscal plan.
4. Potentially minor costs (various funds) to other departments for additional workload necessary for the heads of departments to serve on the task force.
5. Unknown potentially significant future cost pressures to implement the recommendations of the task force, including strategies, accountabilities, deliverables and timeframes necessary for achieving the master plan’s goals and tracking the plan’s progress.

COMMENTS:

1. Purpose. This bill seeks to provide a framework to discuss and address the needs of California’s aging population. According to the author:

The older adult population in California is one whose numbers are swelling – 1,000 people turn 65 every day in California, and more than 20 percent of the state’s population will be age 65 or older by the year 2030. And as this population’s numbers grow, so does its rate of poverty – as it stands today, more than 20 percent of Californians aged 65 and older, or about 900,000 people, live in poverty.

Without adequate services and planning, many of our state’s older adults face a risk of becoming homeless or losing access to essential care. We cannot afford to leave our aging adults behind. California must step up and prepare for this rapidly growing population. Despite the programs and services administered by a range of state departments, families struggle to weave together services and financial care in the hope of helping loved ones remain at home.

1. Background. In 2015, the Senate Select Committee on Aging and Long-Term Care released a report stating:

To date, California has not responded to the increase in the aging population or the rich cultural and ethnic diversity of the state. We are plagued by a lack of capacity – especially in rural areas – in services, supports, and workforce across a range of disciplines.

Reliance upon our existing patchwork of programs and services to serve our growing aging and disabled population will result in unnecessary expenditures, inequitable access, and irrelevant services. Furthermore, under the existing fragmented structure there is no leader to oversee or coordinate the entire range of services, and no mechanism for accountability or improvement.

1. Governor’s Executive Order. On June 10, 2019, Governor Newsom signed Executive Order N-14-19 calling for the establishment of a master plan for aging by October 1, 2020, to:

Serve as a blueprint for state government, local government, private sector, and philanthropy to implement strategies and partnerships that promote healthy aging and prepare the state for the coming demographic changes.

This executive order also directs the Secretary of the Health and Human Services Agency to convene a Cabinet-level Workgroup for Aging to advise the secretary in developing and issuing the master plan. The executive order further directs the California Health and Human Services Agency to convene a Master Plan for Aging Stakeholder Advisory Committee, to include a Research Subcommittee and a Long-Term Care Subcommittee representing a broad range of Californians with an interest in building an age-friendly California. The Long-Term Care Subcommittee is directed to report to the Governor by March 2020 on a number of factors related to long-term services and supports.

It is unclear how the provisions of this bill will interact with the efforts outlined in the executive order.

1. Technical amendment needed. On page 7, line 28, “paragraph (4)” should be amended to read “paragraph (10)” to correct a typographical error.
2. Bill Package. This bill is part of a five-bill Master Plan for Aging package. Additional bills, all of this legislative session, include:

AB 1136 (Nazarian) addresses system fragmentation and the need for state-level administrative reorganization of aging and disability services. That bill was held on this committee’s Suspense File.

AB 1287 (Nazarian) addresses access to a coordinated system of information and supports through a “No Wrong Door” approach. That bill is pending hearing in the Senate Human Services Committee.

AB 1382 (Aguiar-Curry) of 2019 requires the Master Plan for Aging include an implementation plan specifying objectives, and timelines relative to both the paid workforce and unpaid family caregiver workforce. That bill is pending hearing in the Senate Human Services Committee.

SB 611 (Caballero) requires the Governor to establish the Master Plan for Aging Housing Task Force to assess the housing issues affecting California’s aging population. That bill is pending hearing in the Assembly Aging and Long-Term Care Committee.

Analysis Prepared by: Jennifer Swenson / APPR. / (916) 319-2081

Date of Hearing: July 2, 2019

ASSEMBLY COMMITTEE ON HUMAN SERVICES

Eloise Gómez Reyes, Chair

SBPCA Bill Id:SB 228

Author:(Jackson) – As Amended Ver:April 25, 2019

SENATE VOTE: 38-0

SUBJECT: Master Plan on Aging

SUMMARY: Requires the Governor to appoint a Master Plan Director and establishes an Aging Task Force to work together with the Master Plan Director to develop a Master Plan for an Aging California that meets a number of specified criteria and that empowers older adults and individuals with disabilities to age with dignity, choice, and independence. Specifically, this bill:

1. Makes a number of Legislative findings and declarations related to: California’s growing population of older adults; the various needs of older adults and their families, communities, and the state; the multitude of state entities that provide services for older adults, people with disabilities, and their families; and, previous attempts to address system change that have not come to full fruition.
2. States Legislative intent that, in enacting the provisions of this bill, a Master Plan for an Aging California is developed that empowers all Californians, including older adults and individuals with disabilities, to age with dignity, choice, and independence.
3. Requires the Governor to appoint a Master Plan Director to lead the Master Plan for Aging planning process and, further, requires this director to have experience working in the field of aging or long-term care, as specified.
4. Establishes the Aging Task Force, to consist of a total of 13 members, appointed as follows:
   1. Two members appointed by the President pro Tempore of the Senate, with one appointee having expertise in long-term services and supports (LTSS);
   2. Two members appointed by the Speaker of the Assembly, with one appointee having expertise in LTSS; and,
   3. Nine members appointed by the Governor, with each appointee having experience working in the state or local level in the field they represent and with preference given to individuals representing marginalized communities, and with one appointee representing each of the following fields: consumer advocates, health care, long-term services and supports, labor, transportation, housing, schools of gerontology, local government, and business.
5. Requires the Master Plan Director to, in order to develop strategies and responses to the aging of California’s population, work with representatives of state agencies including, but not limited to, the Department of Health Care Services, the California Department of Social Services, the California Department of Aging (CDA), the Department of Rehabilitation, the Department of Transportation, the Department of Housing and Community Development, the Department of Insurance and the Insurance Commissioner, the Department of Veterans Affairs, the Department of Finance, the Chancellor of the California Community Colleges, the Chancellor of the California State University, the President of the University of California Office, and the Judicial Council.
6. Requires the Master Plan Director to, with the assistance of the Aging Task Force, work with representatives from impacted state departments, stakeholders, and any other agencies deemed appropriate, to identify policies that need to be implemented to prepare for the aging of California’s population and that are in accordance with the goals and core values set forth by the provisions of this bill, as specified.
7. Requires the task force to, under the leadership of the Master Plan Director, ensure that the master plan is centered on core values of equity, self-determination, efficiency, system rebalancing that prioritizes home- and community-based services, coordination and integration, and access, as specified.
8. Requires the Master Plan Director to, by July 1, 2021, oversee the completion of an environmental analysis, with which the task force may assist at the director’s discretion, that surveys existing LTSS programs and services for older adults and people with disabilities across the continuum of home- and community-based care to institutional care and that identifies the availability of programs and services in each county to determine where unmet needs exist.
9. Requires information from the environmental analysis to be included on the web-based platform described by provisions of this bill and to be used to map services and inform individuals about LTSS, as specified.
10. Requires the task force, under the leadership of the Master Plan Director, to develop a master plan in accordance with the core values specified by provisions of this bill that identifies possible actions that would accomplish all of the following, as specified:
    1. Preparing the state to address the needs of older adults, people with disabilities, and caregivers;
    2. Improving the quality and effectiveness of service delivery;
    3. Ensuring adequate and sustainable funding for Medi-Cal and other state and local LTSS programs;
    4. Enabling older adults and people with disabilities to live in the most integrated, community-based setting;
    5. Fostering opportunities for older adults and people with disabilities to be meaningfully engaged in their communities;
    6. Supporting the workforce, including unpaid family caregivers, that serves this population;
    7. Developing effective communication models for providing information about available LTSS to individuals who lack access to digital technology;
    8. Outlining strategies and tactics with criteria for prioritizing near- and long-term action items, with the highest priority action items including, but not being limited to, programs and policies that: impact health, safety, and well-being; enable individuals to receive services in home- and community-based settings versus institutionalization; and, lift older adults, people with disabilities, and families out of poverty;
    9. Establishing benchmarks to assess and measure progress in accomplishing the master plan goals;
    10. Including a cost estimate and potential funding sources for accomplishing, at the least, all of the following, as specified:
        1. Expanding access to coordinated, integrated systems of care by: developing a web-based platform that streamlines access to information and supports through a No Wrong Door system; developing and implementing a universal assessment tool as part of the No Wrong Door system; and, developing a statewide, integrated, coordinated service delivery system that builds upon and improves California’s Coordinated Care Initiative;
        2. Preparing families to plan and pay for LTSS;
        3. Supporting family caregivers;
        4. Increasing access to LTSS, health care, and related services to address unmet need;
        5. Developing affordable living options, including those allowing individuals to age in place and access assistive technology;
        6. Enhancing accessible public transportation;
        7. Developing a culturally competent workforce that meets the needs of older adults and individuals with disabilities;
        8. Preventing exploitation and abuse of older adults and people with disabilities; and,
        9. Streamlining state administrative structures to improve service delivery;
11. Requires the master plan, under the leadership of the Master Plan Director, to include and be implemented in accordance with a fiscal plan and timeline for building LTSS infrastructure, prioritizing areas where unmet need is the most acute.
12. Requires the Aging Task Force, under the leadership of the Master Plan Director, to develop and implement a process to solicit input from a wide variety of stakeholders and to convene community-specific forums to gather information on the impact on the community of California’s aging population and, further, requires the task force to ensure that underserved communities are represented and culturally competent resources provided.
13. Requires the Aging Task Force to develop an implementation process that describes strategies, accountabilities, deliverables, and timeframes necessary for achieving the master plan’s goals.
14. Requires the Aging Task Force to develop a process that will track, monitor, and evaluate progress on the implementation of the master plan.
15. Requires the Master Plan Director to work with the Legislature and other state agencies to identify statutory and regulatory changes necessary to implement the master plan.
16. Requires, by January 1, 2021, the Chancellor of the Community Colleges and California State University to develop, and authorizes the President of the University of California to develop, a strategy and fiscal plan to ensure the availability of a culturally competent workforce to meet the needs of an aging population by 2030.

EXISTING LAW:

1. Reauthorizes the Older Americans Act of 1965 to, among other things, protect vulnerable seniors and promote the delivery of evidence-based programs. (Public Law [PL] 114-144)
2. Establishes the Mello-Granlund Older Californians Act to reflect the policy mandates and directives of the Older Americans Act of 1965, as amended, and sets forth California’s commitment to its older population and other populations served by programs administered by CDA. (Welfare and Institutions Code [WIC] Section 9000 et seq.)
3. Establishes the Aging and Disability Resource Connection (ADRC) program to provide information to consumers and their families regarding available LTSS programs and to assist older adults, caregivers, and persons with disabilities in accessing local LTSS programs, and sets forth requirements related to the administration and responsibilities of an ADRC program. (WIC 9120)
4. Describes, within the federal Patient Protection and Affordable Care Act, the “No Wrong Door – Single Entry Point System” as the development of a statewide system to enable consumers to access all LTSS through an agency, organization, coordinated network, or portal, in accordance with state-established standards, that provides information regarding the availability of such services, how to apply for such services, referral for services and supports otherwise available in the community, and determinations of financial and functional eligibility for such services and supports, or assistance with assessment processes for financial and functional eligibility. (PL 111-148 Section 10202 (c)(5)(A))

FISCAL EFFECT: According to the Senate Appropriations Committee on May 13, 2019, this bill may result in the following costs:

• Unknown costs, in the mid to high hundreds of thousands of dollars for salary, operating expenses, equipment, and support staff for the Master Plan Director (General Fund [GF]);
• Unknown costs, likely mid hundreds of thousands of dollars for an unspecified state agency, to establish and administer the Task Force. This would include consulting services and state staff support to provide research and administrative support to the Task Force (GF);
• Unknown, potentially significant costs to the Community Colleges and the California State University to research and develop a strategy and fiscal plan (GF);
• Potentially minor costs to other departments for additional workload necessary for the heads of departments to serve on the Task Force (various funds); and,
• Unknown potentially significant future cost pressures to implement the recommendations of the task force, including strategies, accountabilities, deliverables, and timeframes necessary for achieving the master plan’s goals and tracking the plan’s progress.

COMMENTS:

California’s aging population and associated needs: CDA reports that the portion of California’s population over the age of 60 is anticipated to grow by 166% between 2010 and 2060. The number of Californians in this age group will grow three times as fast as the state’s overall population in the coming decades. The population of Californians over the age of 85 will grow at an even faster rate, with an estimated overall increase of 489% between the years 2010 and 2060.

A 2015 report by the Public Policy Institute of California described higher population growth rates among certain racial/ethnic groups:

“The number of seniors in every major racial/ethnic group will increase by 2030. Whites will remain the largest group and are projected to grow by 53 percent (1.5 million people). However, the fastest rates of growth will occur among nonwhite populations, especially Latinos (170%, or 1,430,000 people) and Asians (118% or 765,000 people). The African American senior population will increase by 96 percent, or 230,000 people.

Because Latino and Asian senior populations are growing so quickly, they will make up an increasing share of the total over-65 population going forward. Since 1990, there has been a steady decline in the percent of seniors who are white, and by 2030 that fraction is expected to dip to just below 50 percent. At that point, no ethnic group will constitute a majority of the senior population. Latinos will have increased from 18 percent in 2012 to 26 percent by 2030; Asians will grow from 14 percent to 16 percent. The fraction of seniors who are African American will hold constant at 5 percent.”

Legislative and other efforts in past years have pointed to the need to meet the growing demand for culturally competent services and supports among older adults and individuals with disabilities and to the need for better coordination of service availability and delivery across the myriad programs and services in the state. For example, in 2015, the Senate Select Committee on Aging and Long-Term Care released a report that stated that,

“To date, California has not responded to the increase in the aging population or the rich cultural and ethnic diversity of the state. We are plagued by a lack of capacity – especially in rural areas – in services, supports, and workforce across a range of disciplines.

The challenge before us is two-fold. First, over 5.1 million persons age 65 an over will call California home by 2015. Due to aging Baby Boomers and migration patterns, that number will grow to 8.4 million by 2030 – or nearly one fifth of the population. Second; as the Baby Boom population ages, it will become more ethnically diverse, driving demand for culturally competent service delivery.

Reliance upon our existing patchwork of programs and services to serve our growing aging and disabled population will result in unnecessary expenditures, inequitable access, and irrelevant services. Furthermore, under the existing fragmented structure there is no leader to oversee or coordinate the entire range of services, and no mechanism for accountability or improvement.”

Governor’s Executive Order: On June 10, 2019, Governor Newsom signed an executive order (Executive Order N-14-19) calling for the establishment of a Master Plan for Aging by October 1, 2020, to “serve as a blueprint for state government, local government, private sector, and philanthropy to implement strategies and partnerships that promote healthy aging and prepare the state for the coming demographic changes.” This executive order also directs the Secretary of the Health and Human Services Agency to convene a Cabinet-level Workgroup for Aging to advise the Secretary in developing and issuing the master plan, and directs the California Health and Human Services Agency to convene a Master Plan for Aging Stakeholder Advisory Committee, to include a Research Subcommittee and a Long-Term Care Subcommittee representing a broad range of Californians with an interest in building an age-friendly California; the Long-Term Care Subcommittee is directed to report to the Governor by March 2020 on a number of factors related to long-term services and supports.

Need for this bill: According to the author, “The older adult population in California is one whose numbers are swelling – 1,000 people turn 65 every day in California, and more than 20 percent of the state’s population will be age 65 or older by the year 2030. And as this population’s numbers grow, so does its rate of poverty – as it stands today, more than 20 percent of Californians aged 65 and older, or about 900,000 people, live in poverty. These challenges also hit women harder than men. Traditionally, women live five years longer than men, more often end up living alone, and are in poorer health. The longer they live, the greater the odds they will live in poverty, and if a woman is living alone, those odds are even higher.

“We have so much to do between now and 2030 to get ready for the coming wave of older Californians. It isn’t enough to build accessible, affordable housing. It isn’t enough to train as many as 500,000 more healthcare workers. We also need to bring a new perspective to the challenges facing seniors, innovative solutions to the problems we’ve faced for generations. We want robust communities, housing choices, and readily available health care. We need to look at the obstacles comprehensively. That is what [this bill] seeks to do – provide a framework for state and local officials to look at and address the challenges facing California and its older citizens.

“The states of Connecticut, Washington and Minnesota have comprehensively planned for the coming demographic shift, and [this bill] will provide a similar framework for California, encouraging collaboration among state departments and stakeholders and building on known best practices and research to provide both a vision and a practical plan for addressing the long- and short-term needs and challenges of aging and disabled Californians. Through increased coordination, services can be delivered more efficiently, maximizing resources dedicated to these programs. Improved coordination will also make the system more navigable for both recipients of care as well as their caregivers.”

Double referral: This bill passed out of the Assembly Aging and Long Term Care Committee on June 25, 2019, with a 7-0 vote.

RELATED AND PRIOR LEGISLATION:

AB 1136 (Nazarian) of 2019 would have created the “California Department of Community Living” to better coordinate and guide a person-centered system for delivering services to older adults, people with disabilities, and their caregivers. AB 1136 was held on the Assembly Appropriations Committee suspense file.

AB 1287 (Nazarian) of 2019 would require the development of a plan and strategy for the statewide implementation of the No Wrong Door system and the development of a universal assessment tool to assist older adults, people with disabilities, and caregivers in obtaining accurate information and appropriate community services and supports. AB 1287 is set to be heard on July 8, 2019, in the Senate Human Services Committee.

AB 1382 (Aguiar-Curry) of 2019 would require that the Master Plan for Aging include an implementation plan specifying objectives, and timelines relative to both the paid workforce and unpaid family caregiver workforce. AB 1382 is set to be heard on July 8, 2019, in the Senate Human Services Committee.

SB 611 (Caballero) of 2019 would require the Governor to establish the Master Plan for Aging Housing Task Force (Task Force) to assess the housing issues affecting California’s aging population. SB 611 is set to be heard on July 9, 2019, in the Assembly Aging and Long-Term Care Committee.

SB 910 (Vasconcellos et al.), Chapter 948, Statutes of 1999, required the University of California to compile information that addressed the impending demographic, economic, and social changes triggered by California’s aging society.

REGISTERED SUPPORT / OPPOSITION:

Support

California Association for Health Services at Home
California Association of Area Agencies on Aging
California Association of Public Authorities for IHSS
California Commission on Aging
California Dental Hygienists Association
California School Employees Association
California State Association of Counties
CaliforniaHealth+ Advocates
Community Clinic Association of Los Angeles County
County of Contra Costa
County of Los Angeles Board of Supervisors
County of Sacramento
County of Santa Clara
Jewish Public Affairs Committee
Meals on Wheels
National Association of Social Workers, California Chapter
Retired Public Employees Association
San Diego Regional Chamber of Commerce
State Independent Living Council
UDW/AFSCME Local 3930

Opposition

None on file

Analysis Prepared by: Daphne Hunt / HUM. S. / (916) 319-2089

Date of Hearing: June 25, 2019

ASSEMBLY COMMITTEE ON AGING AND LONG-TERM CARE

Adrin Nazarian, Chair

SBPCA Bill Id:SB 228

Author:(Jackson) – As Amended Ver:April 25, 2019

SENATE VOTE: 38-0

SUBJECT: Master Plan on Aging

SUMMARY: This bill requires the Governor to appoint a Master Plan Director (Director) and establishes an Aging Task Force to work with representatives from state departments, stakeholders, and other agencies to identify the policies and priorities needed in California to better serve the growing population of older adults and people with disabilities. This bill requires the Task Force to develop a master plan with specified components, including, among others, a proposal, including a cost estimate and an identification of potential funding sources, to guide how the state should accomplish specific goals, as specified. Specifically, this bill:

1. States a series of legislative findings that California’s aging population is growing at a substantial rate and the current landscape of services and programs are not equipped to meet the magnitude of need, and that as Californians age, the demand for health care, long-term services and supports, affordable housing, transportation and health care will continue to outpace supply unless there is intentional leadership and action to study and recommend a plan of action.
2. States that 20% of the state’s older adults live in poverty, reflecting a vulnerable and compelling need for focused care and attention.
3. States that 90% of adults prefer to age in place but lack access to the necessary services and supports to do so. Families currently shoulder the cost of unpaid caregiving and without supportive information and training.
4. Requires the Governor to appoint a Master Plan Director to the lead the Master Plan process.
5. Creates an Aging Task Force consisting of 13 members, with appointments by the Governor, the President Pro Tem of the Senate, and the Speaker of the Assembly.
6. Tasks the Master Plan Director to work with representatives from various enumerated state departments and stakeholders, as defined.
7. Requires the Task Force to ensure that the Master Plan is focused on the core values of equity, self-determination to age in place and empower the individual voice, achieve government efficiency, coordinating and streamlining programs; to achieve “re-balancing” so that home-based services receive primary focus as alternatives to institutionalization; and, that geographic access is achieved.
8. By July 1, 2021, the Director shall complete a landscape survey analysis of existing program capacity with the information mapped county-by-county and be made available on-line.
9. Requires the task force to develop a master plan in accordance with the core values specified previously and that identifies possible actions that would prepare the State to accomplish addressing the needs of older adults, people with disabilities, and their caregivers; and that
10. Improves the quality and effectiveness of service delivery;
11. Ensures adequate and sustainable funding for Medi-Cal and other state and local long term services and supports (LTSS) programs;
12. Enables older adults and people with disabilities to live in the most integrated and community-based setting;
13. Provides opportunities for older adults and people with disabilities to be meaningfully engaged in their communities;
14. Supports the workforce, including unpaid family caregivers;
15. Develops effective communication models for providing long term services and supports information to those in the community who lack access to digital technology; and,
16. Outlines strategies and tactics with criteria for prioritizing near-term and long-term action items.
17. Requires the highest priority action items to include programs and policies which affect the health and mental health and well-being of older adults and people with disabilities and their caregivers, to receive services in home and community-based settings, to lift older adults and people with disabilities out of poverty.
18. Establishes benchmarks to assess and measure progress in accomplishing the master plan goals.
19. Establishes a cost estimate and identify funding sources to accomplish at a minimum expanded access to coordinated systems of care.
20. Develop a web-based platform that streamlines access to information and supports through a No Wrong Door system.
21. Develop and implement a universal assessment tool to be utilized as part of the No Wrong Door system, enabling streamlined access to LTSS programs.
22. Develop a statewide, integrated, coordinated service delivery system.
23. Prepare families to plan and pay for LTSS.
24. Support family caregivers by providing opportunities for respite services, training, and support in the home setting.
25. Increase access to LTSS, health care to address unmet need, and to develop a culturally competent paraprofessional and professional workforce that meets the needs of older adults and people with disabilities.
26. Develop affordable housing options, including those allowing individuals to age in place and access assistive technology in the home environment, and access to transportation.
27. Prevent exploitation and abuse, including financial abuse and physical abuse, of older adults and people with disabilities.
28. Requires the Master Plan to include a fiscal plan and timeline for building long-term services and supports infrastructure, prioritizing areas where unmet need is the most acute.
29. Requires the Aging Task Force to convene community-specific public forums to gather information and to ensure that underserved communities are represented and that culturally competent resources are provided.
30. Requires the Task Force to develop an implementation process describing strategies, accountabilities, deliverables, and timeframes necessary for achieving the master plan’s goals and to measure and evaluate progress towards those goals.
31. Requires the Director to work with the Legislature and other state agencies to identify statutory and regulatory changes needed for implementation of the Master Plan.
32. Requires by January 1, 2021, the Chancellor of the Community Colleges and California State University shall develop, and President of the University of California may develop, a strategy and fiscal plan to ensure the availability of a culturally competent workforce to meet the needs of an aging population by 2030.

EXISTING LAW:

1. Establishes Medicare, a federal health insurance program for aged and disabled people. (42 USC 1395 et seq.)
2. Establishes the Medicaid program, under which health care services are provided to qualified, low-income persons. (42 USC 1396 et seq.)
3. Establishes, in federal law, the Older Americans Act, which promotes the well-being of Americans 60 years of age and older through services and programs designed to meet the specific needs of older citizens. Services provided under the Older Americans Act include home-delivered and communal meals; family caregiver support; health services home assistance for the elderly; job training and volunteer opportunities; and protections from elder abuse (42 U.S. Code 3001, et seq.)
4. Provides for the licensure of health facilities, including skilled nursing facilities (SNFs), by the Department of Public Health and defines “SNF” as a health facility that provides skilled nursing care and supportive care to patients whose primary need is for availability of skilled nursing care on an extended basis. (HSC 1250 et seq.)
5. Establishes the Medi-Cal program, which is California’s Medicaid, to provide various health and long-term services to low-income women, parents and caretaker adults, children, elderly, people with disabilities and, under the Affordable Care Act, adults without children or who are not pregnant between the ages of 19 and 65. (WIC 1400 et seq.)
6. Establishes the Mello-Granlund Older Californians Act, which establishes the California Department of Aging (CDA), and sets forth its duties and powers, including, among other things, entering into a contract for the development of information and materials to educate Californians on the concept of “aging in place.” (WIC 9100 et seq.)
7. Vests in the Department of Rehabilitation (DOR) the responsibility and authority to encourage the planning, development, and funding of independent living centers, which are private, nonprofit organizations that provide specified services to individuals with disabilities, in order to assist those individuals in their attempts to live fuller and freer lives outside institutions. (WIC 19000 et seq.)
8. Establishes the In-Home Supportive Services (IHSS) program to provide supportive services for aged, blind, or disabled persons who are unable to perform the tasks themselves and who cannot safely remain in their homes unless such services are provided. Those supportive services include, but are not limited to, domestic services, heavy cleaning, personal care services, and accompaniment during travel to health-related appointments or to alternative resource sites, yard hazard abatement, protective supervision, and paramedical services, as defined. (WIC 12300 et seq.)
9. Establishes the Aging and Disability Resource Connection (ADRC) program to provide information to consumers and their families regarding available long-term services and supports (LTSS) programs and to assist older adults, caregivers, and persons with disabilities in accessing local LTSS programs, and sets forth requirements related to the administration and responsibilities of an ADRC program. (WIC 9120)
10. Describes, within the federal Patient Protection and Affordable Care Act, the “No Wrong Door – Single Entry Point System” as the development of a statewide system to enable consumers to access all LTSS through an agency, organization, coordinated network, or portal, in accordance with state-established standards, that provides information regarding the availability of such services, how to apply for such services, referral for services and supports otherwise available in the community, and determinations of financial and functional eligibility for such services and supports, or assistance with assessment processes for financial and functional eligibility. (PL 111-148 Section 10202 (c)(5)(A)).
11. Includes the Olmstead v. LC decision in which the Supreme Court held that people with disabilities have a qualified right to receive state funded supports and services in the community rather than institutions.
12. Establishes the Americans with Disabilities Act of 1990 (ADA), which protects the rights of people with disabilities. 42 U.S.C. § 12101(a)(2), (5).

FISCAL EFFECT: According to the Senate Appropriations Committee:

• Unknown costs, in the mid to high hundreds of thousands of dollars for salary, operating expenses, equipment, and support staff for the Master Plan Director. (GF)
• Unknown costs, likely mid hundreds of thousands of dollars for an unspecified state agency, to establish and administer the Task Force. This would include consulting services and state staff support to provide research and administrative support to the Task Force. (GF)
• Unknown, potentially significant costs to the Community Colleges and the California State University to research and develop a strategy and fiscal plan. (GF)
• Potentially minor costs to other departments for additional workload necessary for the heads of departments to serve on the Task Force. (various funds)
• Unknown potentially significant future cost pressures to implement the recommendations of the task force, including strategies, accountabilities, deliverables, and timeframes necessary for achieving the master plan’s goals and tracking the plan’s progress.

COMMENTS:

According to the Author: “Without adequate services and planning, many of our state’s older adults face a risk of becoming homeless or losing access to essential care. We cannot afford to leave our aging adults behind. California must step up and prepare for this rapidly growing population.

Twenty percent of California’s older adults live in poverty, and this number is expected to increase with the aging of the state. Despite the programs and services administered by a range of state departments, families struggle to weave together services and financial care in the hope of helping loved ones remain at home.”

Need for this bill: There is substantial energy and focus among stakeholders, the Governor, and Members of the Legislature regarding the need to convene a discussion around the needs of California’s older adults and people with disabilities. The Californians over-65 population is anticipated to grow by 87% between 2012 and 2030, representing an increase of more than 4 million people. For the first time, older Californians will outnumber young children. In 25 years, the population will double. More than half will require some form of long-term services and supports.

To help prepare for and better respond to the needs of California’s older adults in a coordinated fashion, this bill would establish the Master Plan Aging Task Force and a Director to guide its efforts. The state has previously created master plans for critical issues in California, such as higher education and transportation. The master plans help serve as guiding tools which span generations by laying out a clear vision and comprehensive approach to solving problems. Effective master plan efforts include the input of many experts, advocates, and key stakeholders across the state, and an inclusive, transparent process to capture input and consolidate a range of good ideas and strategies.

Governor Newsom: In his first State of the State speech on February 12^th, 2019, Governor Newsom called for a Master Plan on Aging. On June 10^th, the Governor issued Executive Order N-14-19 calling for the Master Plan on Aging to be developed including recommendations to better serve the needs of older adults, their families and caregivers, and to better coordinate programs at the federal, state, and local level. The Executive Order would accomplish these actions by establishing a cabinet-level work group led by the Secretary of Health & Human Services Agency and comprised of peer agency heads. The Health & Human Services Agency would also convene Master Plan Stakeholder Advisory Committee which would include a Research Subcommittee and a Long-term Care Subcommittee whose membership reflects a diverse array of members to help support the work of the Master Plan. The Executive Order calls for an interim report on long term care to be released March 1, 2020, and for a final Master Plan Report to be issued October 1, 2020. The Master Plan is to include key data indicators with 10-year targets to support implementation of the Master Plan.

This bill would support and guide the Master Plan discussion by empowering older adults and people with disabilities to age with dignity, choice, and independence. It lays out a detailed framework to accomplish the goals of a master plan guided by core values of equity, self-determination, and a focus on achieving home and community-based care.

Double referral: This bill will be referred to the Assembly Human Services Committee should it pass out of this committee.

Related Legislation: There are a number of proposals authored this year by Members of the Legislature and which echo the priority of the Executive Order to convene a high level task force and also build out areas of focus. The following bills are from the current session, and are all part of the “Master Plan on Aging” bill package:

• AB 1287 (Nazarian) Requires the development of a plan and strategy for the statewide implementation of the No Wrong Door system and the development of a universal assessment tool to assist older adults, people with disabilities, and caregivers in obtaining accurate information and appropriate community services and supports. This bill is set to be heard in Senate Human Services.
• AB 1382 (Aguiar-Curry) Focuses on the need to develop, sustain, and support the workforce as part of a Master Plan for Aging. This bill is set to be heard in Senate Human Services.
• SB 611 (Caballero) Focuses on the need for affordable, accessible housing for older adults as part of the Master Plan for Aging. Passed the Assembly Housing and Community Development Committee with amendments on June 19, 2019 and was re-referred to the Assembly Aging and Long-Term Care Committee.

REGISTERED SUPPORT / OPPOSITION:

Support

Agency on Aging\Area 4 (AAA4)

Alzheimer’s Association

California Alliance for Retired Americans (CARA)

California Assisted Living Association (CALA)

California Association of Area Agencies on Aging (C4A)

California Association for Health Services at Home (CAHSAH)

California Association of Public Authorities for IHSS

California Collaborative for Long-Term Services and Supports

California Commission on Aging

CaliforniaHealth+Advocates

California School Employees Association (CSEA), AFL-CIO

Community Clinic Association of Los Angeles County

Congress of California Seniors

Contra Costa County

County of Santa Clara

Elder & Dependent Adult Abuse Prevention Council of San Luis Obispo County

Jewish Public Affairs Committee of California (JPAC)

LeadingAge

Los Angeles County Board of Supervisors

Meals on Wheels California

National Association of Social Workers, California Chapter (NASW-CA)

Retired Public Employees Association (RPEA)

Sacramento County Board of Supervisors

Santa Barbara Women’s Political Committee (SBWPC)

United Domestic Workers of America-AFSCME Local 3930/AFL-CIO

Ventura County Board of Supervisors

Opposition

None on file.

Analysis Prepared by: Gail Gronert / AGING & L.T.C. / (916) 319-3990

 THIRD READING  

Bill No: SB 228

Author: Jackson (D), et al.

Amended: 4/25/19

Vote: 21

SENATE HUMAN SERVICES COMMITTEE: 6-0, 4/22/19

AYES: Hurtado, Stone, Beall, Jackson, Pan, Wiener

SENATE APPROPRIATIONS COMMITTEE: 6-0, 5/16/19

AYES: Portantino, Bates, Bradford, Hill, Jones, Wieckowski

SUBJECT: Master Plan on Aging

SOURCE: Author

DIGEST:

This bill requires the Governor to appoint a Master Plan Director and establishes an Aging Task Force for the purpose of developing a Master Plan on Aging, as specified. This bill also requires the Office of the Chancellor of the Community Colleges and California State University to develop, and authorizes the Office of the President of the University of California to develop, a strategy and fiscal plan to ensure the availability of a culturally competent workforce.

ANALYSIS:

Existing federal law:

1. Establishes Medicare, a federal health insurance program for aged and disabled people. (42 USC 1395 et seq.)
2. Establishes the Medicaid program, under which health care services are provided to qualified, low-income persons. (42 USC 1396 et seq.)
3. Establishes in federal law the Older Americans Act, which promotes the well-being of Americans 60 years of age and older through services and programs designed to meet the specific needs of older citizens. Services provided under the Older Americans Act include home-delivered and communal meals; family caregiver support; health services home assistance for the elderly; job training and volunteer opportunities; and protections from elder abuse (42 U.S. Code 3001, et seq.)

Existing state law:

1. Establishes the Medi-Cal program, which is California’s version of Medicaid, to provide various health and long-term services to low-income women, parents and caretaker adults, children, elderly, people with disabilities and, under the Affordable Care Act, adults without children or who are not pregnant between the ages of 19 and 65. (WIC 14000 et seq.)
2. Establishes the Mello-Granlund Older Californians Act, which establishes the California Department of Aging (CDA), and sets forth its duties and powers, including, among other things, entering into a contract for the development of information and materials to educate Californians on the concept of “aging in place.” (WIC 9100 et seq.)
3. Vests in the Department of Rehabilitation (DOR) the responsibility and authority to encourage the planning, development, and funding of independent living centers, which are private, nonprofit organizations that provide specified services to individuals with disabilities, in order to assist those individuals in their attempts to live fuller and freer lives outside institutions. (WIC 19000 et seq.)

This bill:

1. States a series of Legislative findings and declarations regarding the impact the aging population will have on older adults and people with disabilities, as well as their families, local communities, and the state.
2. States Legislative intent that a Master Plan for an Aging California is developed that empowers all Californians, including older adults and people with disabilities, to age with dignity, choice, and independence.
3. Requires the Governor to appoint a Master Plan Director to lead the planning process for the Master Plan for Aging, as specified.
4. Establishes the Aging Task Force, which consists of 13 members to be appointed as specified.
5. Requires the Master Plan Director to, with the assistance of the Aging Task Force, work with representatives from impacted state departments and stakeholders to identify policies that need to be implemented to prepare for the aging of California’s population, as specified.
6. Requires the director to work with representatives of state agencies to develop strategies and responses to the aging of California’s population.
7. Requires the Aging Task Force to, under the leadership of the director, ensure the master plan is centered on specified core values.
8. Requires the director to, by July 1, 2021, oversee the completion of a county-by-county environmental analysis surveying the existing long-term services and supports (LTSS) programs and services for older adults and people with disabilities, which the task for may assist with developing, as specified.
9. Requires that information derived from the environmental analysis be included in a Web-based platform and used to map services and inform older adults, people with disabilities, and families about available LTSS.
10. Requires the Aging Task Force to, under the leadership of the director, develop a master plan in accordance with specified core values that identifies possible actions that would prepare the state to address the needs of older adults, people with disabilities, and caregivers, as specified.
11. Requires the Aging Task Force to, under leadership of the director, develop and implement a process to solicit input and convene forums to gather information on the impact on the community of California’s aging population, as specified.
12. Requires the Aging Task Force to develop an implementation process describing strategies, accountabilities, deliverables, and timeframes necessary for achieving the master plan’s goals.
13. Requires the Aging Task Force to develop a process that will track, monitor, and evaluate progress on implementation of the master plan.
14. Requires the director to work with the Legislature and other state agencies to identify statutory and regulatory changes that are needed to implement the master plan.
15. Requires, as part of the aging master planning process, the Chancellor of the Community Colleges and California State University to develop, and permits the President of the University of California to develop, a strategy and fiscal plan to ensure the availability of a culturally competent workforce to meet the needs of an aging population by 2030.

Background

Aging Demographics. In California, the senior population is projected to increase by 4 million in the next ten years. In 40 years, California’s Department of Finance projects California’s senior population will grow to approximately 13.5 million. According to AARP, California’s age 85 and older population will grow 243 percent from 2015 to 2050 and the state’s age 65 and older population will increase 119 percent.

With longevity comes increased need for care. This indicates higher number of individuals with chronic conditions associated with aging and increasing cost of LTSS. Seventy percent of people over 65 will need assistance with performing activities of daily living in order to continue living in their homes.

Complex System of Long-Term Care (LTC) and Services for Individuals Living with Disabilities. California's LTC system is made up of numerous programs at the state, regional, and local levels. A the state level, policies adopted and administered by the Departments of Aging, Health Care Services, Insurance, Social Services, Transportation, Rehabilitation and more have profound impact on the aging population. Locally, many different programs, which may be administered by local government entities or by community based organizations, serve older adults. In many communities, multiple agencies administer LTSS and have complex and duplicative intake, assessment, and eligibility functions. This can create a lack of access to coordinated services and cause consumers and their families to struggle with identifying and accessing necessary home and community-based services. Going without these services can increase the likelihood of hospitalization and institutional placements.

For individuals living with a disability, the system of support is bifurcated at the state level. While the Department of Developmental Disabilities serves individuals with developmental disabilities that originate before 18 years of age, the California Department of Rehabilitation (DOR) serves individuals who have a physical or mental impairment that occurred after 18 years of age and impedes their ability to secure employment.

Need for Coordinated Policy Direction. Multiple reports have called for systemic change in the state’s LTSS system to address the socioeconomic needs and demands of our growing and increasingly diverse older adult population. According to a report by the Senate Select Committee on Aging and Long Term Care, A Shattered System: Envisioning and Implementing an IDEAL Long-Term Care System in California, the long-term care system has been, “adversely impacted by system fragmentation, a lack of usable data, poor planning, unaddressed workforce issues, capacity issues, and of course devastating budget cuts during the recession.” SB 228 includes recommendations from this report.

There are numerous efforts underway to address this growing need for a comprehensive statewide strategy to develop a person-centered, culturally appropriate long-term care system that would enable individuals to receive services in the most affordable, home-like settings available.

Governor Newsom announced plans to develop a Master Plan on Aging that will address “person-centered care, the patchwork of public services, social isolation, bed-locked seniors in need of transportation, the nursing shortage and demand for In-Home Supportive Services that far outpaces its capacity.” The Newsom administration is reportedly developing the Governor’s Master Plan, which may be adopted via Executive Order(s). According to representatives from the administration, the Governor’s Master Plan on Aging will serve as a blueprint that can be used by state government, local communities, private organizations, and philanthropy to build environments that promote healthy aging.

This bill creates a “Master Plan Director” to lead the planning process for a Master Plan on Aging. It also establishes an Aging Task Force, consisting of 13 members that would represent consumer advocates, health care, long-term services and supports, labor, transportation, housing, schools of gerontology, local government, and business. The Master Plan Director would provide leadership to the task force.

The Master Plan Director is also charged with working with representatives from impacted state departments, stakeholders, and any other agencies the director or task force deems appropriate, to identify policies that need to be implemented to prepare for the aging of California’s population and that are in accordance with the core values and goals laid out in this bill.

Recognizing the need to develop a workforce to serve the needs of the older adults and people living with disabilities, this bill also requires the Office of the Chancellor of the Community Colleges and California State University to develop, and authorizes the Office of the President of the University of California to develop, a strategy and fiscal plan to ensure the availability of a culturally competent workforce to by 2030.

Comments

According to the author, “The fundamental problem that SB 228 tries to address is a lack of planning for an aging population.” One thousand people turn 65 every day in California, and more than 20 percent of the state’s population will be age 65 or older by the year 2030. “We have so much to do between now and 2030 to get ready for the coming wave of older Californians. It isn’t enough to build accessible, affordable housing. It isn’t enough to train as many as 500,000 more healthcare workers. We also need to bring a new perspective to the challenges facing seniors, innovative solutions to the problems we’ve faced for generations. We want robust communities, housing choices, and readily available health care. We need to look at the obstacles comprehensively. That is what SB 228 seeks to do – provide a framework for state and local officials to look at and address the challenges facing California and its older citizens,” the author states.

This issue of LTC and other needs of the surging aging population has recently elevated in profile. Governor Newsom has announced plans to create a statewide Master Plan on Aging and an Alzheimer’s Prevention and Preparedness Task Force. At this point, it is unclear how the Master Plan on Aging, as created in this bill, would intersect with the Governor’s Master Plan on Aging, but the author’s office has indicated a willingness to work with the Governor’s office on their mutual goals.

California’s system of providing services and support to senior citizens consists of a myriad of federal, state, local and non-profit entities. The fact that there is no single state-wide entity dedicated to all policy decisions that affect the older adults and the disability community may have contributed to the lack of coordination in the current system. As this bill acknowledges, planning decisions in almost every policy area affect the lives of older adults and the disability community. Under the current structure, the specialized needs of older adults and the disability community can be drowned out by those of other, equally important, populations. Creating a Master Plan Director charged with overseeing policies and dedicated to addressing the interests of older adults and the disability community would likely bring a high powered voice to the public dialog.

Related/Prior Legislation

SB 512 (Pan, 2019) establishes the California LTSS Benefits Board and requires the Board to manage and invest revenue deposited in the California LTSS Benefits Trust Fund, which is also created by SB 512, for the purpose of financing LTSS for eligible individuals. This bill is awaiting a floor vote in the Senate.

AB 1136 (Nazarian, 2019) establishes the California Department of Community Living and requires that department to establish a statewide No Wrong Door system to support seamless access to information regarding available long-term services and supports, as provided. This bill did not pass out of Assembly Appropriations Committee.

AB 1287 (Nazarian, 2019) requires CDA to develop a plan and strategy for a phased statewide implementation of the No Wrong Door system, as specified. This bill also requires the California Health and Human Services Agency to develop a universal tool and process to assess individual need and determine initial eligibility for programs and services available in the LTSS delivery network and requires the agency to submit a legislative report on that tool, as specified. This bill is pending a floor vote in the Assembly.

AB 1382 (Aguiar-Curry, 2019) requires the state to develop a Master Plan for Aging, emphasizing workforce priorities, as provided in this section. Requires the Master Plan for Aging to prioritize the specified issues related to preparing and supporting California’s paid paraprofessionals, professionals, and unpaid family caregiver. This bill is pending a floor vote in the Assembly.

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: No

According to the Senate Appropriations Committee, this bill would likely have the following fiscal effect:

• Unknown costs, in the mid to high hundreds of thousands of dollars for salary, operating expenses, equipment, and support staff for the Master Plan Director. (GF)
• Unknown costs, likely mid hundreds of thousands of dollars for an unspecified state agency, to establish and administer the Task Force. This would include consulting services and state staff support to provide research and administrative support to the Task Force. (GF)
• Unknown, potentially significant costs to the Community Colleges and the California State University to research and develop a strategy and fiscal plan. (GF)
• Potentially minor costs to other departments for additional workload necessary for the heads of departments to serve on the Task Force. (various funds)
• Unknown potentially significant future cost pressures to implement the recommendations of the task force, including strategies, accountabilities, deliverables, and timeframes necessary for achieving the master plan’s goals and tracking the plan’s progress.

SUPPORT: (Verified 5/15/19)

California Assisted Living Association

California Association for Health Services At Home

California Association of Public Authorities for IHSS

California Collaborative for Long-Term Services and Supports

California Commission on Aging

CalPACE

LeadingAge California

National Association of Social Workers, California Chapter

UDW/AFSCME Local 3930

OPPOSITION: (Verified 5/15/19)

None received

Prepared by: Taryn Smith / HUMAN S. /

5/18/19 10:54:45

**** END ****

SENATE COMMITTEE ON APPROPRIATIONS

Senator Anthony Portantino, Chair

2019 - 2020 Regular Session

SB 228 (Jackson) - Master Plan on Aging

Bill Summary:

SB 228 would require the Governor to appoint a Master Plan Director (Director) and establish an Aging Task Force. This bill would also require the Office of the Chancellor of the Community Colleges and California State University, and authorize the Office of the President of the University of California to develop a strategy and fiscal plan to ensure the availability of a culturally competent workforce to meet the needs of an aging population by 2030.

Fiscal Impact:

• Unknown costs, in the mid to high hundreds of thousands of dollars for salary, operating expenses, equipment, and support staff for the Master Plan Director. (GF)
• Unknown costs, likely mid hundreds of thousands of dollars for an unspecified state agency, to establish and administer the Task Force. This would include consulting services and state staff support to provide research and administrative support to the Task Force. (GF)
• Unknown, potentially significant costs to the Community Colleges and the California State University to research and develop a strategy and fiscal plan. (GF)
• Potentially minor costs to other departments for additional workload necessary for the heads of departments to serve on the Task Force. (various funds)
• Unknown potentially significant future cost pressures to implement the recommendations of the task force, including strategies, accountabilities, deliverables, and timeframes necessary for achieving the master plan’s goals and tracking the plan’s progress.

Background:

In California, the senior population is projected to increase by 4 million in the next ten years. In 40 years, California’s Department of Finance projects California’s senior population will grow to approximately 13.5 million.

Long term services and supports (LTSS) are the services and supports used by individuals of all ages with functional limitations and chronic illnesses who need assistance to perform routine activities of daily living such as bathing, dressing, preparing meals, and administering medications. LTSS can be home based care, which is provided by personal care aides, home health aides, and caregivers or in community based settings, which are provided at assisted living facilities, adult day care, respite care, senior centers and meal programs. Additionally, LTSS may occur as facility based care provided in nursing homes, intermediate care facilities, and other 24-hour care settings.

Approximately 20 percent of the people who need LTSS live in an institutional setting. The remaining 80 percent living in the community primarily reside in private homes and residential care facilities for the elderly. For those living at home, most receive assistance from unpaid family and friends (referred to as informal caregivers), some pay for assistance, and low-income households may qualify for Medicaid (Medi-Cal in California) services via the IHSS program.

There are several options for paying for LTSS: one can purchase long-term care (LTC) insurance; pay out of pocket; for those who or qualify, Medicaid (Medi-Cal in California) or Medicare may cover some LTSS expenses. Paid in-home care costs about $26 per hour, which means 20 hours of weekly care would cost about $2,250 per month. The average cost of assisted living in California in 2018 was $4,070 per month. However, that price ranges from $1,020 to $10,720, depending on the geographic region. According to the Public Policy Institute, nursing home care in 2014 averaged $7,500 a month for a semi-private room and $8,666 a month for a private room. Adult day services for 5 days a week cost about $20,000 per year.

According to a report by the Senate Select Committee on Aging and Long Term Care, A Shattered System: Envisioning and Implementing an IDEAL Long-Term Care System in California, the long-term care system has been, “adversely impacted by system fragmentation, a lack of usable data, poor planning, unaddressed workforce issues, capacity issues, and of course devastating budget cuts during the recession.”

Governor Newsom has announced plans to develop a Master Plan on Aging that will address “person-centered care, the patchwork of public services, social isolation, bed-locked seniors in need of transportation, the nursing shortage and demand for In-Home Supportive Services that far outpaces its capacity.” The Newsom administration is reportedly developing the Governor’s Master Plan, which may be adopted via Executive Order(s). According to representatives from the administration, the Governor’s Master Plan on Aging will serve as a blueprint that can be used by state government, local communities, private organizations, and philanthropy to build environments that promote healthy aging.

Proposed Law:

This bill would create the position of Master Plan Director and establish an Aging Task Force. Specifically, this bill would:

• State Legislative intent that a Master Plan for Aging California is developed that empowers all Californians, including older adults and people with disabilities, to age with dignity, choice, and independence;
• Require the Governor to appoint a Director, who has experience working in the field of aging or long-term care, preferably with experience in both service delivery and state policy impacting older adults and people with disabilities, to lead the planning process for the Master Plan for Aging;
• Establish the Aging Task Force consisting of 13 members, as specified;
• Require the Director to, with the assistance of the Aging Task Force, work with representatives from impacted state departments, stakeholders, and any other appropriate agencies, to identify policies that need to be implemented to prepare for the aging of California’s population;
• Specify the core values that the Task Force will ensure that the master plan is centered on;
• Require the Director by July 1, 2021, to oversee the completion of an environmental analysis surveying the existing LTSS programs and services for older adults and people with disabilities across the continuum of home- and community-based care to institutional care. The environmental analysis shall identify the availability of programs and services on a county-by-county basis and determine where unmet needs exist. The task force may assist with the development of the environmental analysis survey;
• Require the information derived from the environmental survey to be included on a web-based platform, as specified, and to be used to map services and inform older adults, people with disabilities, and families about available LTSS;
• Require the master plan to include and be implemented in accordance with a fiscal plan and timeline for building long-term services and supports infrastructure, prioritizing areas where unmet need is the most acute;
• Require the Task Force, under the leadership of the Director, to develop and implement a process to solicit input from a wide variety of stakeholders, convene community-specific public forums to gather information on the impact on the community of California’s aging population, and ensure that underserved communities are represented and that culturally competent resources are provided;
• Require the Task Force to develop an implementation process describing strategies, accountabilities, deliverables, and timeframes necessary for achieving the master plan’s goals; and develop a process that will track, monitor, and evaluate progress on implementation of the master plan;
• Require the Director to work with the Legislature and other state agencies to identify statutory and regulatory changes that are needed to implement the master plan;
• Require, by January 1, 2021, the Chancellor of the Community Colleges and California State University and authorize the President of the University of California to develop a strategy and fiscal plan to ensure the availability of a culturally competent workforce to meet the needs of an aging population by 2030.

Related Legislation:

SB 512 (Pan, 2019) would establish the California LTSS Benefits Board and require the Board to manage and invest revenue deposited in the California LTSS Benefits Trust Fund for the purpose of financing LTSS for eligible individuals. The measure is pending in the Senate Appropriations Committee.

SB 611 (Caballero, 2019), among other things, would establish the Master Plan for Aging Housing Task Force to make recommendations to the Legislature for legislation that will help increase the supply of affordable housing for older adults and reduce barriers to providing health care and social services to older adults in affordable housing. The measure is pending in the Senate Appropriations Committee.

AB 567 (Calderon, 2019) would establish a task force to design a statewide, public long-term care insurance program. The measure is pending in the Assembly Appropriations Committee.

AB 1382 (Aguiar-Curry, 2019) would require the state to develop a Master Plan for Aging, emphasizing workforce priorities, as provided in this section. It would also require the Master Plan for Aging to prioritize the following issues related to preparing and supporting California’s paid paraprofessionals, professionals, and unpaid family caregiver. The measure is pending in the Assembly Appropriations Committee.

Staff Comments:

SB 228 would require the Task Force to develop an implementation process that includes strategies, accountabilities, deliverables, and timeframes necessary for achieving the master plan’s goals; and a process that will track, monitor, and evaluate progress on implementation of the master plan. To the extent these recommendations are implemented, the bill creates significant cost pressures to provide funding to address those issues, or to shift the priorities of existing programs to provide more funding for these programs and services at the expense of other populations.

-- END --

SENATE COMMITTEE ON HUMAN SERVICES

Senator Hurtado, Chair

2019 - 2020 Regular

Bill No: SB 228

Subject: Master Plan on Aging

SUMMARY

This bill requires the Governor to appoint a Master Plan Director and establishes an Aging Task Force, as specified. The bill would require the Director, with the assistance of the Task Force, to work with representatives from impacted state departments, stakeholders, and other agencies to identify the policies and priorities that need to be implemented in California to prepare for the aging of its population. This bill requires the Task Force to develop a master plan with specified components, including, among others, a proposal, with a cost estimate and an identification of potential funding sources, for how the state should accomplish specific goals, as specified.

This bill also requires, as part of the master planning process, the Office of the Chancellor of the Community Colleges and California State University to develop, and authorize the Office of the President of the University of California to develop, a strategy and fiscal plan to ensure the availability of a culturally competent workforce to meet the needs of an aging population by 2030.

ABSTRACT

Existing Law:

1. Establishes Medicare, a federal health insurance program for aged and disabled people. (42 USC 1395 et seq.)
2. Establishes the Medicaid program, under which health care services are provided to qualified, low-income persons. (42 USC 1396 et seq.)
3. Establishes, in federal law, the Older Americans Act, which promotes the well-being of Americans 60 years of age and older through services and programs designed to meet the specific needs of older citizens. Services provided under the Older Americans Act include home-delivered and communal meals; family caregiver support; health services home assistance for the elderly; job training and volunteer opportunities; and protections from elder abuse (42 U.S. Code 3001, et seq.)
4. Provides for the licensure of health facilities, including skilled nursing facilities (SNFs), by the Department of Public Health and defines “SNF” as a health facility that provides skilled nursing care and supportive care to patients whose primary need is for availability of skilled nursing care on an extended basis. (HSC 1250 et seq.)
5. Establishes the Medi-Cal program, which is California’s Medicaid, to provide various health and long-term services to low-income women, parents and caretaker adults, children, elderly, people with disabilities and, under the Affordable Care Act, adults without children or who are not pregnant between the ages of 19 and 65. (WIC 1400 et seq.)
6. Establishes the Mello-Granlund Older Californians Act, which establishes the California Department of Aging (CDA), and sets forth its duties and powers, including, among other things, entering into a contract for the development of information and materials to educate Californians on the concept of “aging in place.” (WIC 9100 et seq.)
7. Vests in the Department of Rehabilitation (DOR) the responsibility and authority to encourage the planning, development, and funding of independent living centers, which are private, nonprofit organizations that provide specified services to individuals with disabilities, in order to assist those individuals in their attempts to live fuller and freer lives outside institutions. (WIC 19000 et seq.)
8. Establishes the In-Home Supportive Services (IHSS) program to provide supportive services for aged, blind, or disabled persons who are unable to perform the tasks themselves and who cannot safely remain in their homes unless such services are provided. Those supportive services include, but are not limited to, domestic services, heavy cleaning, personal care services, and accompaniment during travel to health-related appointments or to alternative resource sites, yard hazard abatement, protective supervision, and paramedical services, as defined. (WIC 12300 et seq.)
9. Establishes the Coordinated Care Initiative (CCI) that requires DHCS to seek federal approval to establish demonstration sites in up to eight counties to provide coordinated Medi-Cal and Medicare benefits to persons who are dually eligible and authorizes DHCS to require seniors and persons with disabilities who are eligible for Medi-Cal only (not Medicare) to mandatorily enroll in Medi-Cal managed care plans. (WIC 14132.275)

This Bill:

1. States a series of Legislative findings and declarations regarding the impact the aging population will have on older adults and people with disabilities, as well as their families, local communities, and the state.
2. States Legislative intent that a Master Plan for Aging California is developed that empowers all Californians, including older adults and people with disabilities, to age with dignity, choice, and independence.
3. Requires the Governor to appoint a Master Plan Director to lead the planning process for the Master Plan for Aging. The Director shall have experience working in the field of aging or long-term care for a minimum of five years, preferably with experience in both service delivery and state policy impacting older adults and people with disabilities. The Director shall possess an understanding of the issues relating to aging and long-term care and a familiarity with relevant stakeholders. The Director shall possess strong interpersonal skills with the ability to work collaboratively with, and develop consensus among, multiple groups, including, but not limited to, state representatives, providers, consumers, and advocates. The Director shall express a commitment to developing a comprehensive Master Plan for Aging that addresses the range of issues impacting California’s older adults, people with disabilities, and caregivers.
4. Establishes the Aging Task Force, which shall consist of 15 members to be appointed as following:
5. Five members by the President pro Tempore of the Senate.
6. Five members by the Speaker of the Assembly.
7. Five members by the Governor.
8. Requires that members of the Task Force include representation from consumers, consumer advocates, or both, health care, long-term services and supports (LTSS), labor, transportation, housing, local government, business, and marginalized communities, and shall have experience working in their field, at the state or local level, for a minimum of five years. Task Force members shall possess knowledge of the field they represent, including in the policy and regulatory context, strong communication skills, and an expressed commitment to developing a comprehensive Master Plan for Aging that addresses the range of issues impacting California’s older adults, people with disabilities, and caregivers.

Requires that the Master Plan Director, with the assistance of the Aging Task Force, work with representatives from impacted state departments, and any other agencies the Director or Task Force deems appropriate, to identify policies that need to be implemented to prepare for the aging of California’s population and that are in accordance with the specified core values.

1. Requires the Director work with representatives of state agencies, including, but not limited to, the heads of 13 specified state agencies, to develop strategies and responses to the aging of California’s population.
2. Requires the Task Force to, under the leadership of the Director, ensure the master plan is centered on all of the following core values:
3. Equity. The master plan shall seek to enable older adults and people with disabilities to access LTSS in accordance with individual needs and preferences, to the extent feasible, regardless of individual health or functional status, income, race, religion, or other socioeconomic factors.
4. Self-determination. The master plan shall seek to enable older adults and people with disabilities to remain in their own homes and communities as long as possible or desired while receiving services and supports that are in line with their individual needs and preferences.
5. Efficiency. The master plan shall seek to reduce unnecessary costs and reduce duplication through streamlined service delivery.
6. System rebalancing. The master plan shall prioritize the delivery of home- and community-based services in a home setting as alternatives to institutionalization, in accordance with individual needs, desires, and preferences.
7. Coordination and integration. The master plan shall seek to streamline service delivery through coordinated and integrated systems of care.
8. Access. The master plan shall ensure access to health care and LTSS in all communities across the state, including rural, suburban, and urban settings.
9. Requires the Task Force, under the leadership of the Director, to complete an environmental analysis surveying the existing LTSS programs and services for older adults and people with disabilities across the continuum of home- and community-based care to institutional care. The environmental analysis shall identify the availability of programs and services on a county-by-county basis and determine where unmet needs exist and must be completed by July 1, 2020.
10. Requires the information derived from the environmental analysis be included on a newly created web-based platform and to be used to map services and inform older adults, people with disabilities, and families about available LTSS.
11. Requires the Task Force to, under the leadership of the Director, develop a master plan that does all of the following:
12. Accomplishes all of the following goals:
13. Prepares the state for the impact of an aging population, while addressing the needs of all who are impacted, including older adults, people with disabilities, and caregivers.
14. Improves the quality and effectiveness of service delivery.
15. Ensures adequate and sustainable funding for Medi-Cal and other state and local LTSS programs.
16. Enables older adults and people with disabilities to live in the most integrated, community-based setting, in accordance with their needs and preferences.
17. Fosters opportunities for older adults and people with disabilities to be meaningfully engaged in their communities.
18. Supports the workforce, including unpaid family caregivers, in serving the population.
19. Develops modes to relay information about available LTSS to older adults, people with disabilities, and families who lack access to digital technology.
20. Outlines strategies and tactics in accordance with specified goals with criteria for prioritizing near-term and long-term action items. The highest priority action items shall include, but not be limited to, all of the following:
21. Programs and policies impacting the mental and physical health, safety, and well-being of older adults, people with disabilities, and families.
22. Programs and policies enabling individuals to receive services in home- and community-based settings as an alternative to institutionalization.
23. Programs and policies that lift older adults, people with disabilities, and families out of poverty.
24. Benchmarks to assess and measure progress in accomplishing the specified master plan goals.
25. Proposes how, and includes with the proposal a cost estimate and an identification of potential funding sources, at a minimum, the state should accomplish all of the following:
26. Expand access to coordinated, integrated systems of care by doing all of the following:
27. Developing a web-based platform that streamlines access to information and supports through a No Wrong Door system.
28.  Developing and implementing a universal assessment tool to be utilized as part of the No Wrong Door system, enabling streamlined access to LTSS programs.
29. Developing a statewide, integrated, coordinated service delivery system that builds upon and improves California’s Coordinated Care Initiative in an effort to better streamline access to services across the medical care and the LTSS continuum.
30. Strengthen access to LTSS, including the development of a fiscal plan and timeline for building LTSS infrastructure in areas where unmet need exists, prioritizing regions with greatest unmet need, as specified.
31. Prepare families to plan and pay for LTSS.
32. Support family caregivers by providing opportunities for respite services, training, and support in the home setting.
33. Increase access to LTSS, health care, and related services where there is significant unmet need, including but not limited to, oral health care, mental health services, and food and nutrition services.
34. Develop affordable housing options, including those allowing individuals to age in place and access assistive technology in the home environment.
35. Enhance access to transportation.
36. Develop a culturally competent paraprofessional and professional workforce that meets the needs of older adults and people with disabilities across the service-delivery system, including health care, mental health care, and specialty areas.
37. Prevent exploitation and abuse, including financial abuse and physical abuse, of older adults and people with disabilities.
38. Streamline state administrative structures to improve service delivery.
39. Identify a phased timeline for implementation, as specified.
40. Requires the Task Force to, under the leadership of the Director, outline a fiscal plan and timeline for building LTSS infrastructure, prioritizing areas where unmet need is the most acute.
41. Requires the master plan be implemented pursuant to the timeline included in the master plan pursuant to paragraph (5) of subdivision (e).
42. Requires, the Aging Task Force to, under the leadership of the Master Plan Director, develop and implement a process to solicit input from a wide variety of stakeholders, and convene community-specific public forums to gather information on the impact on the community of California’s aging population. Requires the Task Force to ensure that underserved communities are represented and that culturally competent resources are provided.
43. Requires the Aging Task Force to develop an implementation process describing strategies, accountabilities, deliverables, and timeframes necessary for achieving the master plan’s goals.
44. Requires the Task Force to develop a process that will track, monitor, and evaluate progress on implementation of the master plan.
45. Requires impacted state departments to work with the Legislature to identify statutory and regulatory changes that are needed to implement the master plan.
46. Requires that, as part of the aging master planning process, the Chancellor of the Community Colleges and California State University develop, by January 1, 2021, and that the President of the University of California may develop, a strategy and fiscal plan to ensure the availability of a culturally competent workforce to meet the needs of an aging population by 2030.

FISCAL IMPACT

This bill has not yet been analyzed by a fiscal committee.

BACKGROUND AND DISCUSSION

Purpose of the Bill:

According to the author, “The fundamental problem that SB 228 tries to address is a lack of planning for an aging population.” One thousand people turn 65 every day in California, and more than 20 percent of the state’s population will be age 65 or older by the year 2030. “We have so much to do between now and 2030 to get ready for the coming wave of older Californians. It isn’t enough to build accessible, affordable housing. It isn’t enough to train as many as 500,000 more healthcare workers. We also need to bring a new perspective to the challenges facing seniors, innovative solutions to the problems we’ve faced for generations. We want robust communities, housing choices, and readily available health care. We need to look at the obstacles comprehensively. That is what SB 228 seeks to do – provide a framework for state and local officials to look at and address the challenges facing California and its older citizens,” the author states.

Aging Demographics

In California, the senior population is projected to increase by 4 million in the next ten years. In 40 years, California’s Department of Finance projects California’s senior population will grow to approximately 13.5 million. According to AARP, California’s age 85 and older population will grow 243 percent from 2015 to 2050 and the state’s age 65 and older population will increase 119 percent.

Causes of the projected rapid growth of senior population include aging baby boomers and increasing longevity, in general. With longevity comes increased need for care. This indicates higher number of individuals with chronic conditions associated with aging and increasing cost of LTSS. Seventy percent of people over 65 will need assistance with performing activities of daily living in order to continue living in their homes.

Long Term Services and Supports (LTSS)

LTSS are the services and supports used by individuals of all ages with functional limitations and chronic illnesses who need assistance to perform routine activities of daily living such as bathing, dressing, preparing meals, and administering medications. LTSS include the wide array of medical and non-medical services provided to people of all ages with impaired mobility, impaired cognitive function, physical or mental disabilities, complex medical needs or chronic disease. Individuals may need these services on a regular or occasional basis, for a few months or a lifetime.

LTSS include personal care services, assistance with health maintenance, assistance with activities of daily living such as bathing, dressing, toileting, and cooking, adult day services, transportation, social services, in-home support care, assisted living, assistive technology, nutrition assistance, person-centered care coordination, and nursing facility services.

LTSS can be home based care, which is provided by personal care aides, home health aides, and caregivers or in community based settings, which are provided at assisted living facilities, adult day care, respite care, senior centers and meal programs. Additionally, LTSS may occur as facility based care provided in nursing homes, intermediate care facilities, and other 24-hour care settings.

Approximately 20 percent of the people who need LTSS live in an institutional setting. The remaining 80 percent living in the community primarily reside in private homes and residential care facilities for the elderly. For those living at home, most receive assistance from unpaid family and friends (referred to as informal caregivers), some pay for assistance, and low-income households may qualify for Medicaid (Medi-Cal in California) services via the IHSS program.

Paying for LTSS

There are several options for paying for LTSS: one can purchase long-term care (LTC) insurance; pay out of pocket; for those who or qualify, Medicaid (Medi-Cal in California) or Medicare may cover some LTSS expenses.

Private pay LTC insurance has not met its promise of an affordable option to help meet LTSS needs. Such policies require an annual premium in return for financial assistance if/when policy holders need help with activities of daily living or nursing home care as they age. These policies can be cost prohibitive and recent reports indicate that the cost will increase over time. Additionally, insurance companies are dropping LTC coverage from their menu of optional coverage. According to AARP, more than 100 insurers sold such policies in the 1990s and fewer than 15 were offering LTC policies in 2018. Few Californians have private long-term care insurance. According to AARP, despite the need to cover these costs, only about 800,000 private LTC insurance policies are in effect in California. Because of the low take-up rates, the overwhelming majority of private pay LTSS is paid for out of pocket rather than by insurance.

The out of pocket expense to provide LTSS for older adults is often unaffordable for seniors on a fixed income. As the level of care increases, so does the cost. Paid in-home care costs about $26 per hour, which means 20 hours of weekly care would cost about $2,250 per month. The average cost of assisted living in California in 2018 was $4,070 per month. However, that price ranges from $1,020 to $10,720, depending on the geographic region. According to the Public Policy Institute, nursing home care in 2014 averaged $7,500 a month for a semi-private room and $8,666 a month for a private room. Adult day services for 5 days a week cost about $20,000 per year.

Government healthcare programs that cover LTSS include Medicaid (Medi-Cal in California) and Medicare. Medi-Cal is available for individuals who meet income eligibility. Medicare is available for those who meet age requirements. However, neither program adequately covers LTSS (even for people who are eligible for both). Medicare only pays for short-term rehabilitative care. Medi-Cal pays for personal care and supportive services, but income and asset limits can force older adults to spend down their savings or sell their homes in order to qualify for help through Medi-Cal. This scenario forces people into poverty in their later years in order to access the care they need.

Of the $192 billion spent on formal LTSS in 2011, about two-thirds was paid by Medicare and Medi-Cal. The remainder was paid out-of-pocket by consumers or by private insurance. More than half of LTSS are provided as informal care. The Congressional Budget Office estimates that the value of informal care provided in 2011 was approximately $234 billion.

Complex System of Long-Term Care (LTS) and Need to Coordinate Policy Direction

California's LTC system is made up of numerous programs at the state, regional, and local levels. In many communities, multiple agencies administer LTSS and have complex and duplicative intake, assessment, and eligibility functions. This can create a lack of access to coordinated services and cause consumers and their families to struggle with identifying and accessing necessary home and community-based services. Going without these services can increase the likelihood of hospitalization and institutional placements.

Multiple reports have called for systemic change in the state’s LTSS system to address the socioeconomic needs and demands of our growing and increasingly diverse older adult population. According to a report by the Senate Select Committee on Aging and Long Term Care, A Shattered System: Envisioning and Implementing an IDEAL Long-Term Care System in California, the long-term care system has been, “adversely impacted by system fragmentation, a lack of usable data, poor planning, unaddressed workforce issues, capacity issues, and of course devastating budget cuts during the recession.^[1]”

The report goes on to say, “Reliance upon our existing patchwork of programs and services to serve our growing aging and disabled population will result in unnecessary expenditures, inequitable access, and irrelevant services. Furthermore, under the existing fragmented structure there is no leader to oversee or coordinate the entire range of services, and no mechanism for accountability or improvement.” SB 228 includes recommendations from this report.

There are numerous efforts underway to address this growing need for a comprehensive statewide strategy to develop a person-centered, culturally appropriate long-term care system that would enable individuals to receive services in the most affordable, home-like settings available.

Governor Newsom has announced plans to develop a Master Plan on Aging that will address “person-centered care, the patchwork of public services, social isolation, bed-locked seniors in need of transportation, the nursing shortage and demand for In-Home Supportive Services that far outpaces its capacity.” The Newsom administration is reportedly developing the Governor’s Master Plan, which may be adopted via Executive Order(s). According to representatives from the administration, the Governor’s Master Plan on Aging will serve as a blueprint that can be used by state government, local communities, private organizations, and philanthropy to build environments that promote healthy aging.

SB 512 (Pan, 2019) proposes to create the basic infrastructure of a board, trust fund and advisory committee that would be the foundation for a new state-operated LTSS insurance program envisioned to serve the LTSS needs of “middle-class” Californians who are aged or disabled. This is a population that the current LTSS system is not adequately serving. The bill makes one step in a long term plan to create the new LTSS insurance program and provides that the missing elements will be developed after an actuarial study is completed. There will likely be follow up legislation to establish the parameters of the insurance program in the next year or two.

This bill creates a “Master Plan Director” to lead the planning process for the Master Plan on Aging. It also establishes an Aging Task Force, consisting of 15 members that would represent consumers, consumer advocates, or both; health care; LTSS; labor; transportation; housing; local government; business, and marginalized communities.

The Master Plan Director is charged with leading the planning process for the Master Plan on Aging and providing leadership to the Task Force. The Director is also charged with working with representatives from impacted state departments, stakeholders, and any other agencies the Director or Task Force deems appropriate, to identify policies that need to be implemented to prepare for the aging of California’s population and that are in accordance with the core values and goals laid out in the bill.

Among other things, the Task Force is charged with:

• working with representatives from impacted state departments, stakeholders, and any other agencies the director or task force deems appropriate, to identify policies that need to be implemented to prepare for the aging of California’s population:
• completing a county-by-county survey of existing LTSS programs and services for older adult and people with disabilities by July 1, 2020;
• developing a master plan, which must include developing a web-based platform that streamlines access to information and support through a No Wrong Door system., develop and implement a universal assessment tool, and develop a statewide, integrated, coordinated service delivery system that building upon and improve CCI;
• outlining a fiscal plan and timeline for building LTSS infrastructure;
• developing and implementing a process to solicit input from a wide variety of stakeholders and convene community-specific public forums;
• developing an implementation process describing strategies, accountabilities, deliverable, and timeframes necessary for achieving the master plan goals; and
• develop a process that will track, monitor, and evaluate progress on implementation of the master plan.

Related/Prior Legislation:

SB 512 (Pan, 2019) establishes the California LTSS Benefits Board and requires the Board to manage and invest revenue deposited in the California LTSS Benefits Trust Fund, which is also created by SB 512, for the purpose of financing LTSS for eligible individuals. This bill is set to be heard in the Senate Governmental Organization Committee on April 23, 2019.

SB 611 (Caballero, 2019) establishes the Master Plan for Aging Housing Task Force to, among other things, make recommendations to the Legislature for legislation that will help increase the supply of affordable housing for older adults and reduce barriers to providing health care and social services to older adults in affordable housing. This bill is set to be heard in the Senate Housing Committee on April 22, 2019.

AB 567 (Calderon, 2019) establishes a task force to design a statewide, public long-term care insurance program. This bill is set to be heard by the Assembly Labor, Public Employment and retirement Committee on April 24.

AB 1136 (Nazarian, 2019) establishes the California Department of Community Living and requires that department to establish a statewide NWD system to support seamless access to information regarding available long-term services and supports, as provided. This bill has not yet been set for a hearing.

AB 1287 (Nazarian, 2019) states Legislative intent to establish the Master Plan for an Aging California that responds to population needs in a comprehensive manner, including, but not limited to, implementing the No Wrong Door system that facilitates access to a universal assessment process and streamlined information and support and that the No Wrong Door system will support statewide seamless access to LTSS, including universal assessment, while building upon the information and referral standards established through the Aging and Disability Resource Connection program, which is currently limited to eight counties. This bill is waiting to be heard in the Assembly Committee on Aging and Long-Term Care.

AB 1382 (Aguiar-Curry, 2019) requires the state to develop a Master Plan for Aging, emphasizing workforce priorities, as provided in this section. Requires the Master Plan for Aging to prioritize the following issues related to preparing and supporting California’s paid paraprofessionals, professionals, and unpaid family caregiver. This bill is awaiting hearing in the Assembly Long-Term Care Committee.

COMMENTS

This issue of LTC and other needs of the surging aging population has recently elevated in profile. Governor Newsom announced plans to create a statewide Master Plan on Aging and an Alzheimer’s Prevention and Preparedness Task Force. At this point, it is unclear how the Master Plan on Aging, as created in this bill, would intersect with the Governor’s Master Plan on Again, but the author’s office has indicated a willingness to work with the Governor’s office on their mutual goals.

California’s system of providing services and support to senior citizens consists of a myriad of federal, state, local and non-profit entities. The fact that there is no single state-wide entity dedicated to all policy decisions that affect the older adults and the disability community may have contributed to the lack of coordination in the current system. As this bill acknowledges, planning decisions in almost every policy area affect the lives of older adults and the disability community. Under the current structure, the specialized needs of older adults and the disability community can be drowned out by those of other, equally important, populations. Creating a Master Plan Director charged with overseeing policies and dedicated to addressing the interests of older adults and the disability community would likely bring a high powered voice to the public dialog.

While developing a statewide Master Plan on Aging and establishing a Master Plan Director are meritorious, the author might consider amending the bill to allow for more flexibility on the part of the Director and the Task Force.

Most of the deliverables outlined in the bill must be developed by the 15 Task Force appointees who would likely be serving on a part time basis, as their qualifications would indicate otherwise full time employment. It may be more appropriate for the Director to be responsible for much of this work, under advisement of the Task Force and in consultation with other state entities.

Therefore the committee recommends the following amendments:

On page 3, line 1:

(A) The annual cost of 30 hours per week of home care is almost $36,000, three-quarters of the state’s median household income.

(B) The median annual cost of nursing home care is $112,055, more than twice the state’s median household income.

(C) Only 5 percent of Californians aged 40 and older have purchased private long-term care insurance.

On page 3, line 23:

(8) California is woefully unprepared to care for this growing and increasingly diverse demographic. California cannot meet the workforce needs of older adults and people with disabilities, with a growing shortage of paraprofessionals and professionals needed to provide culturally competent care to an increasingly diverse population.

On page 3, line 38:

(11) Recent polling data shows that more than two-thirds of likely voters feel the state is not prepared to address the health care and social support needs of its fast-growing older adult population. Nearly 9 out of 10 voters say it is important for the state to have a master plan to invest in services that allow older adults to age in the place that they prefer.

On page 4, line 18:

(14) According to the 2017 Long-Term Services & Supports State Scorecard, the highest-performing states all have one thing in common: a commitment to a clear and strategic plan that guides thoughtful investments as part of an integrated and responsive approach to serving older adults and people with disabilities. As examples, Connecticut, Washington, and Minnesota have outlined clear strategies with a broad framework for systems improvement. Policymakers and elected officials in these states have collaborated in developing a vision with specific benchmarks and goals that serve as the foundation for achieving broad transformation.

On page 5, line 3:

9800. (a) The Governor shall appoint a Master Plan Director to lead the planning process for the Master Plan for Aging. The director shall have experience working in the field of aging or long-term care for a minimum of five years, preferably with experience in both service delivery and state policy impacting older adults and people with disabilities. The director shall possess an understanding of the issues relating to aging and long-term care and a familiarity with relevant stakeholders. The director shall possess strong interpersonal skills with the ability to work collaboratively with, and develop consensus among, multiple groups, including, but not limited to, state representatives, providers, consumers, and advocates. The director shall express a commitment to developing a comprehensive Master Plan for Aging that addresses the range of issues impacting California’s older adults, people with disabilities, and caregivers.

(b) (1) The Aging Task Force is hereby established. The task force shall consist of 15 13 members to be appointed as following:

(A) Five Two members by the President pro Tempore of the Senate.

(B) Five Two members by the Speaker of the Assembly.

(C) Five Nine members by the Governor.

The Governor shall appoint one representative with expertise from each of the following categories: consumer advocates, health care, long-term services and supports, labor, transportation, housing, school of gerontology, local government, and business. Each appointee shall have experience working in the field they represent, at the state or local level. Preference shall be given to the appointment of people who also represent marginalized communities.

The Senate and the Speaker shall appoint one representative with expertise in the delivery of long-term services and supports.

(2) Members of the task force shall include representation from consumers, consumer advocates, or both, health care, long-term services and supports, labor, transportation, housing, local government, business, and marginalized communities, and shall have experience working in their field, at the state or local level, for a minimum of five years.

Task force members shall possess knowledge of the field they represent, including in the policy and regulatory context, strong communication skills, and an expressed commitment to developing a comprehensive Master Plan for Aging that addresses the range of issues impacting California’s older adults, people with disabilities, and caregivers.

On page 7, line 16:

(d) (1) Under the leadership of the director, the task force shall, by July 1, 2020 July 1, 2021, oversee the completion of complete an environmental analysis surveying the existing LTSS programs and services for older adults and people with disabilities across the continuum of home- and community-based care to institutional care. The environmental analysis shall identify the availability of programs and services on a county-by-county basis and determine where unmet needs exist. The task force may assist with development of the environment analysis survey, as deemed appropriate by the director.

On page 7, line 29:

(e) Under the leadership of the director, the task force shall develop a master plan in accordance with the core values outlined in subdivision (c) that does identifies possible actions that would accomplish all of the following:

(1) Accomplishes all of the following goals:

(A) Prepares the state for the impact of an aging population, while addressing to address the needs of all who are impacted, including older adults, people with disabilities, and caregivers.

On page 8, line 8:

(G) Develops effective communication models for providing modes to relay information about available LTSS to older adults, people with disabilities, and families who lack access to digital technology.

(2) Outlines strategies and tactics in accordance with goals identified in paragraph (1), with criteria for prioritizing near-term and long-term action items. The highest priority action items shall include, but not be limited to, all of the following:

On page 8, line 23:

(3)Establishes Benchmarks to assess and measure progress in accomplishing the master plan goals identified in paragraph (1).

(4)  Includes a cost estimate and potential funding source for how Proposes how, and includes with the proposal a cost estimate and an identification of potential funding sources, at a minimum, the state should could accomplish all of the following:

On page 9, line 1:

(B) Strengthen access to LTSS, including the development of a fiscal plan and timeline for building LTSS infrastructure in areas regions where unmet need exists, prioritizing regions with greatest unmet need, as identified pursuant to paragraph (1) of subdivision (d).

On page 9, line 13:

(E) Increase access to LTSS, health care, and related services where there is to address significant unmet need, including but not limited to, oral health care, mental health services, and food and nutrition services.

On page 9, line 22:

(G) Enhance access to accessible public transportation.

On page 9, line 36:

(5) Identify a phased timeline for implementation, as specified in Section 9815.

(f) Under the leadership of the director, the task force shall outline a master plan shall include, and be implemented in accordance with, a fiscal plan and timeline for building long-term services and supports infrastructure, prioritizing areas where unmet need is the most acute.

(g) The master plan shall be implemented pursuant to the timeline included in the master plan pursuant to paragraph (5) of subdivision (e).

On page 10, line 21:

(c) Impacted state departments The director shall work with the Legislature and other state agencies to identify statutory and regulatory changes that are needed to implement the master plan.

POSITIONS

Support:

California Association for Health Services At Home

California Collaborative for Long-Term Services and Supports

CalPACE

LeadingAge California

National Association of Social Workers, California Chapter

UDW/AFSCME Local 3930

Oppose:

None received

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1. http://www.cicaihss.org/sites/default/files/aginglong_termcarereport.pdf ↑