Existing law establishes the California Health and Human Services Agency, which includes the State Department of Public Health, among other state departments charged with the administration of health, social, and other human services. Existing law requires the agency to convene a working group of representatives to develop a quality standard for patient experience related to the transgender, gender diverse, or intersex (TGI) community and to recommend training curriculum to provide trans-inclusive health care.

This bill would require the agency, or an entity designated by the agency, on or before July 1, 2025, January 1, 2026, to create an internet website website, or update its existing internet website, where the public can access information and resources to support TGI individuals and their families in accessing trans-inclusive health care and other support services in the state, including, but not limited to, a general description of trans-inclusive health care, information on how to access directories of providers providing gender-affirming services, and resources for victims of hate incidents and hate crimes.

The bill would require the agency to consult with specified subject matter experts experts, the Civil Rights Department, and the Department of Justice in creating the internet website. The bill would also require the agency, in consultation with subject matter experts, to maintain the website and review the available information and resources to ensure the website is current and updated at reasonable intervals, but no less than once every year. The bill would authorize the agency to accept donations for the purpose of supporting and maintaining the internet website, and would make those donations available upon appropriation by the Legislature for that purpose.

Existing law establishes the California Health and Human Services Agency, which includes the State Department of Public Health, among other state departments charged with the administration of health, social, and other human services. Existing law requires the agency to convene a working group of representatives to develop a quality standard for patient experience related to the transgender, gender diverse, or intersex (TGI) community and to recommend training curriculum to provide trans-inclusive health care.

This bill would require the agency, or an entity designated by the agency, on or before July 1, 2025, to create an internet website where the public can access information and resources to support TGI individuals and their families in accessing trans-inclusive health care and other support services in the state, including, but not limited to, a general description of trans-inclusive health care, information on how to access directories of providers providing gender-affirming services, and resources for victims of hate incidents and hate crimes.

The bill would require the agency to consult with specified subject matter experts and the Department of Justice in creating the internet website. The bill would also require the agency, in consultation with subject matter experts, to maintain the website and review the available information and resources to ensure the website is current and updated at reasonable intervals, but no less than once every 6 months. year. The bill would authorize the agency to accept donations for the purpose of supporting and maintaining the internet website, and would make those donations available upon appropriation by the Legislature for that purpose.

Existing law establishes the California Health and Human Services Agency, which includes the State Department of Public Health, among other state departments charged with the administration of health, social, and other human services. Existing law requires the agency to convene a working group of representatives to develop a quality standard for patient experience related to the transgender, gender diverse, or intersex (TGI) community and to recommend training curriculum to provide trans-inclusive health care.

This bill would require the agency, or an entity designated by the agency, on or before July 1, 2025, to create an internet website where the public can access information and resources to support TGI individuals and their families in accessing trans-inclusive health care and other support services in the state, including, but not limited to, a general description of trans-inclusive health care, information on how to access directories of providers providing gender-affirming services, and resources for victims of hate incidents and hate crimes.

The bill would require the agency to consult with specified subject matter experts and the Department of Justice in creating the internet website. The bill would also require the agency, in consultation with subject matter experts, to maintain the website and review the available information and resources to ensure the website is current and updated at reasonable intervals, but no less than once every 6 months.

The Equity in Higher Education Act establishes the policy of the state to afford all persons regardless of specified characteristics, including gender, gender identity, gender expression, and sexual orientation, equal rights and opportunities in the postsecondary educational institutions of the state. The act requests the Trustees of the California State University, the Regents of the University of California, and the governing board of each community college district to designate an employee at each of their respective campuses as a point of contact for the needs of lesbian, gay, bisexual, and transgender faculty, staff, and students.

This bill would add queer faculty, staff, and students to the list of individuals for whom the designated employee would serve as a point of contact.

SENATE THIRD READING

STR Bill Id:SB 959

Author:(Menjivar)

As Amended Ver:August 19, 2024

Majority vote

SUMMARY

Requires the California Health and Human Services Agency (CalHHS) to establish a website where the public can access specified information about trans-inclusive health care and related support services for transgender, gender diverse, and intersex (TGI) individuals in California.

Major Provisions

COMMENTS

1. Gender-Affirming Care and Recent Action in Other States. Gender-affirming care is considered safe, effective, and medically necessary by major professional health associations, such as the American Medical Association and American College of Obstetricians and Gynecologists (ACOG). Despite this, according to a 2023 report by the University of California, Los Angeles School of Law, Williams Institute, a growing number of states have taken action to restrict access to this care through proposed or enacted legislation or executive action, including legislative bans on gender-affirming care for youth and young adults.
2. Particular Informational Challenges Related to Gender-Affirming Care. Human Rights Campaign, an LGBTQ+ civil rights organization that monitors state restrictions on gender-affirming care, has asserted that the debate on bills related to such care includes misconceptions and lies. In addition, according to ACOG, lack of awareness, knowledge, and sensitivity as well as bias from health care professionals contributes to inadequate access to, underuse of, and inequities within the health care system for transgender patients. Given these factors, it may be particularly challenging for individuals to identify reliable and trusted information on trans-inclusive health care and related protections.
3. California Protections on Gender-Affirming Care. In recent years, California has enacted numerous laws protecting access to gender-affirming health care and protecting the providers offering such care. California agency interpretation by Department of Managed Health Care (DMHC), California Department of Insurance, and Department of Health Care Services has also generally been protective of individual's access to gender-affirming health care as a medically necessary service for individuals covered by commercial insurance and Medi-Cal. This bill would create a web resource for this type of information. Although some similar resources exist online that address components of this bill's requirements, the author and sponsor emphasize the importance of a state government website in combatting disinformation and providing people information they can trust.

According to the Author

TGI people, especially TGI youth, are confronting an alarming rise in discrimination and violence fueled by misinformation and political attacks. According to the American Civil Liberties Union, over 500 anti-LGBTQ+ bills were introduced in 2023, and 84 were signed into law. The author indicates California must continue leading the nation to ensure that TGI people in California and across the country can access the health care and support services they need. The author asserts this bill will ensure that California provides comprehensive information and resources about access to trans-inclusive health care in the state, as TGI people and their families seek access to affirming health care and support.

Arguments in Support

Cosponsors Equality California, Planned Parenthood Affiliates of California, TransFamily Support Services, and TransYouth Liberation, along with other supporters, write that despite California's strong laws protecting TGI people's access to essential health care, TGI people frequently have trouble finding affirming providers for routine care and identifying health care providers who offer gender-affirming care within their health plan can be even harder. Additionally, TGI individuals often feel unsure about the steps to obtaining care as well as feeling unsure about requirements that may need to be met for care. Supporters assert that as attacks on the TGI community continue to escalate, California must take additional steps to be a nationwide leader in supporting TGI people and their families seeking essential health care.

Arguments in Opposition

The Department of Finance (DOF) writes in opposition to this bill because, according to DOF, it results in ongoing costs not included in the 2024 Budget Act. Additionally, DOF notes existing law established the Office of Health Care Affordability to limit healthcare spending and address prevailing cost drivers. DOF asserts the costs associated with this bill could increase the cost of health care for enrollees, conflicting with the state's goal to slow the growth of health care costs.

FISCAL COMMENTS

According to the Assembly Appropriations Committee, the DMHC anticipates additional workload to support the content of the website and work with the TGI communities to support TGI individuals and their families in accessing trans-inclusive health care and other support services. The website information will be updated annually in consultation with subject matter experts. The workload also includes consultant funding to assist with translation services for the website. The DMHC estimates the cost to be approximately $41,000 in fiscal year 2025-26 and annually thereafter (Managed Care Fund).

VOTES

SENATE FLOOR: 31-8-1

YES: Alvarado-Gil, Archuleta, Ashby, Atkins, Becker, Blakespear, Bradford, Caballero, Cortese, Dodd, Durazo, Eggman, Glazer, Gonzalez, Hurtado, Laird, Limón, McGuire, Menjivar, Min, Newman, Padilla, Portantino, Roth, Rubio, Skinner, Smallwood-Cuevas, Stern, Umberg, Wahab, Wiener

NO: Dahle, Grove, Jones, Nguyen, Niello, Ochoa Bogh, Seyarto, Wilk

ABS, ABST OR NV: Allen

ASM HEALTH: 13-3-0

YES: Bonta, Waldron, Aguiar-Curry, Arambula, Wendy Carrillo, Haney, Jones-Sawyer, Maienschein, McCarty, Rodriguez, Santiago, Lowenthal, Pellerin

NO: Flora, Joe Patterson, Sanchez

ASM JUDICIARY: 9-3-0

YES: Kalra, Bauer-Kahan, Bryan, Connolly, Haney, Maienschein, McKinnor, Pacheco, Reyes

NO: Dixon, Joe Patterson, Sanchez

ASM APPROPRIATIONS: 11-3-1

YES: Wicks, Arambula, Bryan, Calderon, Wendy Carrillo, Mike Fong, Grayson, Haney, Hart, Pellerin, Villapudua

NO: Sanchez, Dixon, Ta

ABS, ABST OR NV: Jim Patterson

UPDATED

VERSION: August 19, 2024

CONSULTANT: Lisa Murawski / HEALTH / (916) 319-2097 FN: 0004079

SENATE THIRD READING

STR Bill Id:SB 959

Author:(Menjivar)

As Amended Ver:August 19, 2024

Majority vote

SUMMARY

Requires the California Health and Human Services Agency (CalHHS) to establish a website where the public can access specified information about trans-inclusive health care and related support services for transgender, gender diverse, and intersex (TGI) individuals in California.

Major Provisions

Click here to enter text.

COMMENTS

1. Gender-Affirming Care and Recent Action in Other States. Gender-affirming care is considered safe, effective, and medically necessary by major professional health associations, such as the American Medical Association and American College of Obstetricians and Gynecologists (ACOG). Despite this, according to a 2023 report by the University of California, Los Angeles School of Law, Williams Institute, a growing number of states have taken action to restrict access to this care through proposed or enacted legislation or executive action, including legislative bans on gender-affirming care for youth and young adults.
2. Particular Informational Challenges Related to Gender-Affirming Care. Human Rights Campaign, an LGBTQ+ civil rights organization that monitors state restrictions on gender-affirming care, has asserted that the debate on bills related to such care includes misconceptions and lies. In addition, according to ACOG, lack of awareness, knowledge, and sensitivity as well as bias from health care professionals contributes to inadequate access to, underuse of, and inequities within the health care system for transgender patients. Given these factors, it may be particularly challenging for individuals to identify reliable and trusted information on trans-inclusive health care and related protections.
3. California Protections on Gender-Affirming Care. In recent years, California has enacted numerous laws protecting access to gender-affirming health care and protecting the providers offering such care. California agency interpretation by Department of Managed Health Care (DMHC), California Department of Insurance, and Department of Health Care Services has also generally been protective of individual's access to gender-affirming health care as a medically necessary service for individuals covered by commercial insurance and Medi-Cal. This bill would create a web resource for this type of information. Although some similar resources exist online that address components of this bill's requirements, the author and sponsor emphasize the importance of a state government website in combatting disinformation and providing people information they can trust.

According to the Author

TGI people, especially TGI youth, are confronting an alarming rise in discrimination and violence fueled by misinformation and political attacks. According to the American Civil Liberties Union, over 500 anti-LGBTQ+ bills were introduced in 2023, and 84 were signed into law. The author indicates California must continue leading the nation to ensure that TGI people in California and across the country can access the health care and support services they need. The author asserts this bill will ensure that California provides comprehensive information and resources about access to trans-inclusive health care in the state, as TGI people and their families seek access to affirming health care and support.

Arguments in Support

Cosponsors Equality California, Planned Parenthood Affiliates of California, TransFamily Support Services, and TransYouth Liberation, along with other supporters, write that despite California's strong laws protecting TGI people's access to essential health care, TGI people frequently have trouble finding affirming providers for routine care and identifying health care providers who offer gender-affirming care within their health plan can be even harder. Additionally, TGI individuals often feel unsure about the steps to obtaining care as well as feeling unsure about requirements that may need to be met for care. Supporters assert that as attacks on the TGI community continue to escalate, California must take additional steps to be a nationwide leader in supporting TGI people and their families seeking essential health care.

Arguments in Opposition

The Department of Finance (DOF) writes in opposition to this bill because, according to DOF, it results in ongoing costs not included in the 2024 Budget Act. Additionally, DOF notes existing law established the Office of Health Care Affordability to limit healthcare spending and address prevailing cost drivers. DOF asserts the costs associated with this bill could increase the cost of health care for enrollees, conflicting with the state's goal to slow the growth of health care costs.

FISCAL COMMENTS

According to the Assembly Appropriations Committee, the DMHC anticipates additional workload to support the content of the website and work with the TGI communities to support TGI individuals and their families in accessing trans-inclusive health care and other support services. The website information will be updated annually in consultation with subject matter experts. The workload also includes consultant funding to assist with translation services for the website. The DMHC estimates the cost to be approximately $41,000 in fiscal year 2025-26 and annually thereafter (Managed Care Fund).

VOTES

SENATE FLOOR: 31-8-1

YES: Alvarado-Gil, Archuleta, Ashby, Atkins, Becker, Blakespear, Bradford, Caballero, Cortese, Dodd, Durazo, Eggman, Glazer, Gonzalez, Hurtado, Laird, Limón, McGuire, Menjivar, Min, Newman, Padilla, Portantino, Roth, Rubio, Skinner, Smallwood-Cuevas, Stern, Umberg, Wahab, Wiener

NO: Dahle, Grove, Jones, Nguyen, Niello, Ochoa Bogh, Seyarto, Wilk

ABS, ABST OR NV: Allen

ASM HEALTH: 13-3-0

YES: Bonta, Waldron, Aguiar-Curry, Arambula, Wendy Carrillo, Haney, Jones-Sawyer, Maienschein, McCarty, Rodriguez, Santiago, Lowenthal, Pellerin

NO: Flora, Joe Patterson, Sanchez

ASM JUDICIARY: 9-3-0

YES: Kalra, Bauer-Kahan, Bryan, Connolly, Haney, Maienschein, McKinnor, Pacheco, Reyes

NO: Dixon, Joe Patterson, Sanchez

ASM APPROPRIATIONS: 11-3-1

YES: Wicks, Arambula, Bryan, Calderon, Wendy Carrillo, Mike Fong, Grayson, Haney, Hart, Pellerin, Villapudua

NO: Sanchez, Dixon, Ta

ABS, ABST OR NV: Jim Patterson

UPDATED

VERSION: August 19, 2024

CONSULTANT: Lisa Murawski / HEALTH / (916) 319-2097 FN: 0004079

Date of Hearing: August 7, 2024

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Buffy Wicks, Chair

SBPCA Bill Id:SB 959

Author:(Menjivar) – As Amended Ver:May 16, 2024

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

SUMMARY:

This bill requires the California Health and Human Services Agency (CalHHS), on or before July 1, 2025, to create a website where intersex (TGI) individuals and their families can access information and resources to support transgender, gender diverse, trans-inclusive health care and other support services.

Specifically, this bill:

1. Requires the website include information about the following:
   
   1. Federal and state protections for TGI individuals accessing trans-inclusive health care.
      
   2. Federal and state protections against criminal or civil penalties or professional discipline based solely on the application of another state’s law that prohibits care that is lawful in this state for health care providers providing gender-affirming care.
      
   3. How to access health plans, Medi-Cal managed care plans, and health insurer directories that identify in-network providers that offer gender-affirming services, as described.
      
   4. Support services to assist an individual in accessing trans-inclusive health care, including transportation, family engagement support, training and education sessions, and translation services.
      
   5. Resources available to assist individuals with health care costs.
      
   6. General description of trans-inclusive health care, including gender-affirming health and mental health care.
      
   7. Countering misinformation and disinformation about trans-inclusive health care, as specified.
      
   8. References and links to additional related information and resources for TGI individuals and their families regarding rights and protections and how to file complaints for any violation of those rights, as specified.
      
   9. Any other information or resources that will help an individual seeking comprehensive and accurate information about trans-inclusive health care and other support services.
      
2. Requires CalHHS to consult with specified subject matter experts and the Department of Justice in creating the website. Requires CalHHS, in consultation with subject matter experts, to maintain the website and review the available information and resources to ensure the website is current and updated at least once every year.
3. Requires the website to have mobile capabilities, comply with accessibility laws, and include a feature to allow users to report erroneous or outdated information. Requires the website and informational materials be translated into Spanish, Chinese, Tagalog, Vietnamese, and Korean, and in compliance with the Dymally-Alatorre Bilingual Services Act.
4. Prohibits the website from including the name or location of any individual who is a provider of gender-affirming services.
5. Authorizes CalHHS to accept donations to support and maintain the website and requires the donations to be available upon appropriation by the Legislature.
6. Defines by reference trans-inclusive health care, gender-affirming health care, and gender-affirming mental health care.

FISCAL EFFECT:

CalHHS would delegate responsibilities for this bill to the Department of Managed Health Care (DMHC). DMHC states its Office of the Director would provide and support the content of the website and work with TGI communities, and its Office of Technology and Innovation would develop and configure the website templates and provide infrastructure support. DMHC estimates the total cost of this bill to be approximately:

• $682,000 in fiscal year (FY) 2025-26.
• $320,000 in FY 2026-27.
• $327,000 in FY 2027-28.
• $336,000 in FY 2028-29.
• $344,000 in FY 2029-30 and annually thereafter.
  

All costs would come from the Managed Care Fund (MCF).

DMHC notes that generally, a $1 million dollar increase to the MCF could result in a 2-cent increase per enrollee on assessments to full-service health plans and a 1-cent increase per enrollee to specialized health plans.

COMMENTS:

1. Purpose. This bill is sponsored by Planned Parenthood Affiliates of California, Equality California, TransFamily Support Services, and TransYouth Liberation. According to the author:

Transgender, gender diverse, and Intersex (TGI) people, especially TGI youth, are confronting an alarming rise in discrimination and violence fueled by misinformation and political attacks. According to the ACLU, over 500 anti-LGBTQ+ bills were introduced in 2023, and 84 were signed into law. These bills disproportionately targeted TGI youth and adults, particularly access to essential health care.

California must continue leading the nation to ensure that TGI people in California and across the country can access the health care and support services they need. SB 959 will ensure that as TGI people and their families seek access to affirming health care and support, California provides comprehensive information and resources about access to trans-inclusive health care in the state.

1. Background.

Gender-Affirming Care. Gender-affirming care, as defined in the Welfare and Institutions Code, is medically necessary health care that respects the gender identity of the patient, as experienced and defined by the patient, and may include interventions to suppress the development of endogenous secondary sex characteristics, interventions to align the patient’s appearance or physical body with the patient’s gender identity, or interventions to alleviate symptoms of clinically significant distress resulting from gender dysphoria, considered safe and effective. According to a 2023 report by the University of California, Los Angeles School of Law, a growing number of states have proposed or enacted legislation or executive action to restrict access to gender-affirming care.

Information Challenges Related to Gender-Affirming Care. Human Rights Campaign, an LGBTQ+ civil rights organization that monitors state restrictions on gender-affirming care, has asserted that the debate on bills related to such care includes misconceptions and lies. In addition, according to the American College of Obstetricians and Gynecologists, lack of awareness, knowledge, and sensitivity, and bias on the part of health care professionals, contribute to inadequate access to, underuse of, and inequities within the health care system for transgender patients.

1. Budget Request. According to the author, a request for a $1 million budget allocation to support the creation of the website was not funded.
2. Prior Legislation.
   1. AB 1707 (Pacheco), Chapter 258, Statutes of 2023, protects health care professionals, clinics, and health facilities from being denied a license or subjected to discipline on the basis of a civil judgment, criminal conviction, or disciplinary action imposed by another state based solely on the application of a law that interferes with a person's right to receive services, including gender-affirming care, that would be lawful in California.
      
   2. SB 923 (Wiener), Chapter 822, Statutes of 2022, requires a Medi-Cal managed care plan, health plan, or health insurer to require staff in direct contact with enrollees to complete evidence-based cultural competency training for providing trans-inclusive health care and adds processes to physicians’ continuing medical education requirements related to cultural and linguistic competency specific to gender-affirming care services.

Analysis Prepared by: Allegra Kim / APPR. / (916) 319-2081

Date of Hearing: June 18, 2024

ASSEMBLY COMMITTEE ON JUDICIARY

Ash Kalra, Chair

SBPCA Bill Id:SB 959

Author:(Menjivar) – As Amended Ver:May 16, 2024

SENATE VOTE: 31-8

SUBJECT: Trans-inclusive care: resources and support services

KEY ISSUE: should the state create an internet website where the public can access information and resources to support transgender, gender nonconforming, and intersex (TGI) individuals and their families in accessing trans-inclusive health care and other support services?

SYNOPSIS

Many studies show that transgender, gender nonconforming, and intersex (TGI) people often have difficulty accessing trans-inclusive health care and other support services. Many of those who do access health services report having negative and even traumatic experiences. This bill would address this problem by requiring the California Health and Human Services Agency (HHSA) to create an internet website to provide TGI people, and their families, with information and resources that will help them access trans-inclusive health care and related support services. Most germane to this Committee, the website will also contain information about existing legal rights and protections for TGI individuals and health care providers. The bill would require HHSA to consult with appropriate subject matter experts and the California Department of Justice in developing this website.

Co-sponsored by Equality California, Planned Parenthood Affiliates of California, Trans Family Support Services, Trans Youth Liberation, and the California LGBTQ+ Legislative Caucus, the bill also has the support of several other civil rights, social justice, and health equity advocates. There is no registered opposition. The bill recently passed out of the Assembly Health Committee on a 13-3 vote.

SUMMARY: Requires the Health and Human Services Agency (HHSA) to create an internet website where the public can access information and resources to support transgender, gender nonconforming, and intersex (TGI) individuals and their families in accessing trans-inclusive health care and other support services, as specified. Specifically, this bill:

1. Requires the HHSA, on or before July 1, 2025, to create an internet website where the public can access information and resources to support TGI individuals and their families in accessing trans-inclusive health care and other support services in the state. Specifies that website should include information about the following:
   1. Existing federal and state protections for TGI individuals accessing trans-inclusive health care.
   2. Existing federal and state protections for health care providers providing gender-affirming health or mental health care against criminal or civil penalties or professional discipline, as described.
   3. Accessing health care plans, Medi-Cal managed care plans, and health insurer directories that identify in-network providers that offer gender-affirming services, as described.
   4. Support services to assist an individual in accessing trans-inclusive health care, including, but not limited to, transportation, family engagement support, training and education sessions, and translation services.
   5. Payment support resources available to assist individuals with health care costs, including coverage options, state programs, and other available assistance.
   6. General description of trans-inclusive health care, including gender-affirming health care and gender-affirming mental health care.
   7. Countering misinformation and disinformation about trans-inclusive health care, including gender-affirming health care and gender-affirming mental health care.
   8. References and links to additional related information and resources for TGI individuals and their families regarding rights and protections and the process for filing complaints for any violation of those rights.
2. Requires HHSA to consult with specified subject matter experts and the Department of Justice in creating the internet website. The bill would also require the agency, in consultation with subject matter experts, to maintain the website and review the available information and resources to ensure the website is current and updated at reasonable intervals, but no less than once every year.

EXISTING LAW:

1. Prohibits business establishments, of every kind whatsoever, from discriminating against any person on the basis of their sex, race, color, religion, ancestry, national origin, disability, medical condition, genetic information, marital status, sexual orientation, citizenship, primary language, or immigration status. Specifies, for these purposes, that “sex” includes, but is not limited to, a person’s gender, and “gender” includes a person’s gender identity and gender expression. “Gender expression” means a person’s gender-related appearance and behavior whether or not stereotypically associated with the person’s assigned sex at birth. (Civil Code Section 51.)
2. Requires the State Department of Public Health’s (CDPH) Office of Health Equity to administer the Transgender Wellness and Equity Fund for purposes of funding grants to create programs, or fund existing programs, focused on coordinating trans-inclusive health care for individuals who identify as transgender, gender nonconforming, or intersex (TGI). (Health & Safety Code Section 150900.)
3. Establishes the Transgender, Gender Variant, and Intersex (TGI) Wellness Reentry Fund in the State Treasury to fund grant programs focused on reentry programs to support TGI people who have experienced carceral systems. (Health & Safety Code Section 150925.)
4. Requires the California Health & Human Services Agency to convene a working group to develop a quality standard for patient experience to measure cultural competency related to the TGI community and recommend training curriculum to provide trans-inclusive health care. Specifies that the working group shall consist of representatives from at least three TGI-serving organizations, at least three individual California residents who identify as TGI, health care providers, and one appointee representing each of the following state agencies:
   1. Department of Managed Health Care.
   2. Department of Insurance.
   3. State Department of Health Care Services.
   4. California Health Benefit Exchange.
   5. CalPERS.
   6. State Department of Public Health (Health & Safety Code Section 150950.)

FISCAL EFFECT: As currently in print this bill is keyed fiscal.

COMMENTS: According to the author, “California must continue leading the nation to ensure that [transgender, gender non-conforming, and intersex] TGI people in California and across the country can access the health care and support services they need.” The author believes that SB 959 will support TGI people seeking access to gender-affirming health care by providing “comprehensive information and resources about access to trans-inclusive health care in the state.” The bill does this by establishing “an online resource for TGI people and their families [that will] provide accurate information about access to trans-inclusive health care, legal protections for patients and providers, and other available support.”

This bill requires the Health and Human Services Agency (HHSA) to create an internet website where the public can access information and resources to support transgender, gender nonconforming, and intersex (TGI) individuals and their families in accessing trans-inclusive health care and other support services. Most of the information posted on the website will pertain to health care and related support services, and the Assembly Health Committee analysis, which previously heard this bill, discussed the problems faced by the TGI community in accessing appropriate and affirming health care. The bill comes to this Committee because the website must also contain information on the “rights and protections” that TGI people have in accessing trans-inclusive health care, as well as the rights of health care professionals to provide such care. The remainder of this analysis focuses on these rights and protections.

Transgender health care rights under existing California law. As stressed by the author and co-sponsors, over the past few years legislators and governors in other states have attempted to restrict LGBTQ+ rights, generally, and transgender rights, in particular. The most troubling of these measures attempt to prohibit, and even criminalize, gender-affirming care for transgender youth. For example, in early 2022 the Texas governor ordered the state’s child welfare agencies to investigate reports that minors had received gender-affirming care as possible “child abuse.” The following year, the Texas legislature passed, and the Governor signed, a law prohibiting health care providers from offering gender-affirming care (from hormone blockers to surgery) to most minors in the state. According to the New York Times, between the beginning of 2022 and the middle of 2023 at least a dozen other states had banned, or severely restricted, access to gender-affirming care for minors. Many of these laws have faced legal challenges, but it is too early to say how many of these laws will fare constitutionally. (New York Times, June 3, 2023.) Curiously, although opponents of transgender care for minors often frame the issue as one of “parental rights,” most of the newly enacted or pending legislation prohibits care even where parents want and are seeking care for their children. The new laws punish parents (for “child abuse” in the case of Texas) as well as health care providers, who in many states would be subject to loss of their license in addition to any fines.

California responded to the rise of transphobic laws elsewhere by offering protection not only to TGI residents of California, but also to TGI people from other states who seek care in California. Specifically, SB 107 (Chap. 810, Stats. 2022) made several changes to existing law in order to ensure that California did not participate in the virtual (if not actual) criminalization of gender-affirming care. For example, SB 107 prohibited health care providers from releasing medical information in response to a criminal or civil subpoena. SB 107 also prohibited law enforcement from participating in the arrest or extradition of an individual pursuant to an arrest warrant based upon another state’s law prohibiting gender-affirming care. Finally, SB 107 prohibited courts from enforcing an order from another state to remove a child from the custody of their parents or guardian if the order stemmed from an alleged violation of the other state’s law prohibiting gender-affirming care for minors.

Even before SB 107, California had been a leader in recognizing and protecting transgender rights. For example, AB 1121 (Chap. 651, Stats. 2013) created an administrative process for persons who had undergone clinically appropriate gender change treatment to change their gender markers in official documents and records. In 2017, the Legislature amended this law to permit a person to change their gender marker to reflect their gender identity, whether or not they had undergone a medical procedure. In 2014 California protected gender identify after death by requiring any official responsible for completing a death certificate to ensure that it represented the deceased’s gender expression. California has also supported, rather than prohibited, transgender surgery. For example, in 2015 California became the first state to pay for gender-affirming surgeries for transgender prison inmates. California’s Medi-Cal interprets California’s antidiscrimination laws to require coverage of gender-affirming care.

Last year, SB 923 (Chap. 822, Stats. 2022) addressed concerns of TGI people, in particular. It required a Medi-Cal managed care plan, health care service plan, or health insurer to require frontline staff to complete evidence-based cultural competency training for providing trans-inclusive health care for TGI individuals. Like the bill now under review, SB 923 sought to overcome barriers that make it difficult for TGI individuals to find trans-inclusive health care or, when they do find it, cause them to have an unnecessarily negative experience. Finally, AB 2218 (Chap. 181, Stats. 2020) established the Transgender Wellness and Equity Fund within the Department of Public Health for the purposes of funding holistic health services for TGI persons throughout California.

This bill is a logical complement to SB 923 and AB 2218, as well as legislative efforts to promote access to appropriate case and to protect TGI rights more generally. Not only will the website required by this bill provide necessary information on accessing trans-inclusive health care to TGI individuals and their families, it will also ensure that TGI individuals understand the specific rights and protections afforded to them by existing law.

ARGUMENTS IN SUPPORT: Equality California (EC), one of the co-sponsors of this bill, argues that, “TGI people, especially TGI youth, are confronting an alarming rise in discrimination and violence, fueled by misinformation and political attacks.” EC points, in particular, to over 500 anti-LGBTQ+ bills, many targeting TGI youth, introduced in 2023. EC contends that this “assault on basic rights” has continued and even accelerated into 2024, with nearly another 500 anti-LGBTQ+ bills introduced nationwide within the first five months of this year. Even though California provides many strong protections, TGI people “frequently have trouble finding affirming providers for routine care, and identifying health care providers who offer gender-affirming care within their health plan can be even harder.” EC believes that this bill will help TGI people understand their rights and options when it comes to seeking trans-inclusive care and locating providers that are able and willing to provide that care. Finally, EC argues that, while other states enact hostile laws targeting LGBTQ+ people, California “must take additional steps to be a nationwide leader in supporting TGI people and their families seeking essential health care.”

The California Academy of Child and Adolescent Psychiatry (CALACAP), writing in support, cites “recent studies by the UCLA Center for Health Policy Research and the Williams Institute [finding] that TGI individuals frequently experience disparities in mental health and health care access.” These and other studies demonstrate that TGI people often do not see a doctor because of fear or lack of knowledge. Of those that did see a doctor in the past year, nearly one-half of those surveyed reported having at least one negative experience because they were transgender. These negative experiences contribute to poorer health outcomes and exacerbate existing health disparities. CALACAP hopes that this bill will address these issues by ensuring that TGI individuals have access to accurate information about their rights, available services, and resources.

REGISTERED SUPPORT / OPPOSITION:

Support

California Legislative LGBTQ+ Caucus (co-sponsor)

Equality California (co-sponsor)

Planned Parenthood Affiliates of California (co-sponsor)

Trans Family Support Services (co-sponsor)

Trans Youth Liberation (co-sponsor)

Access Support Network

American College of Obstetricians and Gynecologists District IX

APLA Health

Asian Americans Advancing Justice Southern California

Bienestar Human Services

California Academy of Child and Adolescent Psychiatry

California Democratic Party

California Faculty Association

California Federation of Teachers

California Transcends

Central California LGBTQ+ Collaborative

Children Now

Courage California

El/La Para TransLatinas

Essential Access Health

Faculty Association of California Community Colleges

Faculty Association of California's Community Colleges

GLIDE

Justice in Aging

Los Angeles LGBT Center

Mental Health America of California

Office of Lieutenant Governor Eleni Kounalakis

Our Family Coalition

Parivar Bay Area

San Francisco Marin Medical Society

San Joaquin Pride Center

Sharp Healthcare

Somos Familia Valle

The Center for Sexuality & Gender Diversity

The Trevor Project

Transgender Health and Wellness Center

Transgender Resource, Advocacy & Network Service

Opposition

None on file

Analysis Prepared by: Tom Clark / JUD. / (916) 319-2334

Date of Hearing: June 11, 2024

ASSEMBLY COMMITTEE ON HEALTH

Mia Bonta, Chair

SBPCA Bill Id:SB 959

Author:(Menjivar) – As Amended Ver:May 16, 2024

SENATE VOTE: 31-8

SUBJECT: Trans-inclusive care: resources and support services.

SUMMARY: Requires the California Health and Human Services Agency (CalHHS) to establish a website where the public can access specified information about trans-inclusive health care and other support services in the state. Specifically, this bill:

1. Requires, on or before July 1, 2025, the CalHHS, or an entity designated by the agency, to establish an internet website where the public can access information and resources to support transgender, gender diverse, and intersex (TGI) individuals and their families in accessing trans-inclusive health care and other support services in the state.
2. Requires the website to include all of the following information and resources:
   1. Federal and state protections for TGI individuals accessing trans-inclusive health care and for health care providers providing such care;
   2. Information on how to access health care plans, Medi-Cal managed care plans, and health insurer directories that identify in-network providers;
   3. Various support services, such as transportation, family support, and translation;
   4. A general description of trans-inclusive health care, including gender-affirming health care and gender-affirming mental health care;
   5. Information to combat misinformation and disinformation about trans-inclusive health care, including gender-affirming health care and gender-affirming mental health care;
   6. References and links to additional related information and resources for TGI individuals and their families, to the extent such information is available to the agency:
      1. Rights and legal protections for TGI individuals to access health care, housing, employment, public accommodations, and other programs free from discrimination;
      2. Filing a complaint with the appropriate government agency following a violation of an individual’s rights;
      3. Accessing legal services;
      4. Resources for victims of hate incidents and hate crimes;
      5. Updating an individual’s name and gender marker on state and federal identification records, including, but not limited to, driver’s licenses, birth certificates, death certificates, passports, and social security cards;
      6. Programs and services for those experiencing, or at risk of experiencing, homelessness; and,
      7. Programs and services to promote economic security, including food and cash assistance programs; and,
   7. Any other information or resources that will assist an individual seeking comprehensive and accurate information about accessing trans-inclusive health care and other support services in the state.
3. Requires the applicable agency or entity to consult with subject matter experts, as defined, and the Department of Justice when determining the information and resources to be posted.
4. Requires the website to have mobile functionality; to be updated regularly, no less than annually; and to comply with existing accessibility requirements. Requires the website to be translated into five enumerated languages and to comply with the Dymally-Alatorre Bilingual Services Act.
   
5. Allows the state to accept donations to support and maintain the website, and makes donations accepted for this purpose available upon appropriation by the Legislature to support and maintain the website.
   
6. Prohibits the inclusion of the name or location of any individual who is a provider of gender-affirming services on the website.

EXISTING LAW:

1. Establishes CalHHS, which consists of the following departments: Aging, Community Services and Development, Developmental Services, Health Care Services (DHCS), Managed Health Care (DMHC), Public Health (DPH), Rehabilitation, Social Services, and State Hospitals. [Government Code (GOV) §12803, §12806]
   
2. Requires CHHS to convene a working group of representatives of the transgender, gender diverse, or intersex (TGI) community and state agencies to develop a quality standard for patient experience related to the TGI community and to recommend training curriculum to provide trans-inclusive health care. [Health and Safety Code (HSC) §150950]
   
3. Requires DPH’s Office of Health Equity to administer the TGI Wellness and Equity Fund for purposes of funding grants to create programs, or funding existing programs, focused on coordinating trans-inclusive health care for individuals who identify as TGI. [HSC §150900]
4. Defines “trans-inclusive health care” as comprehensive health care that is consistent with the standards of care for individuals who identify as TGI, honors an individual’s personal bodily autonomy, does not make assumptions about an individual’s gender, accepts gender fluidity and nontraditional gender presentation, and treats everyone with compassion, understanding, and respect. [Welfare and Institutions Code (WIC) §14197.09]
   
5. Defines “gender-affirming health care” as medically necessary health care that respects the gender identity of the patient, as experienced and defined by the patient, and may include, but is not limited to, interventions to suppress the development of endogenous secondary sex characteristics; interventions to align the patient’s appearance or physical body with the patient’s gender identity; and, interventions to alleviate symptoms of clinically significant distress resulting from gender dysphoria. [WIC §16010.2]
   
6. Defines “gender-affirming mental health care” as mental health care or behavioral health care that respects the gender identity of the patient, as experienced and defined by the patient, and may include, but is not limited to, developmentally appropriate exploration and integration of identity, reduction of distress, adaptive coping, and strategies to increase family acceptance. [WIC §16010.2]
7. Establishes the Dymally-Alatorre Bilingual Services Act, which requires, among other things, that state agencies translate any materials explaining services available to the public into any non-English language spoken by a substantial number of the public served by the agency. [GOV §7290, et seq.]
   

FISCAL EFFECT: According to the Senate Appropriations Committee, CalHHS would likely designate DMHC as responsible for developing and maintaining the website. Unknown ongoing costs for DMHC, likely low hundreds of thousands (Managed Care Fund).

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, TGI people, especially TGI youth, are confronting an alarming rise in discrimination and violence fueled by misinformation and political attacks. According to the American Civil Liberties Union, over 500 anti-LGBTQ+ bills were introduced in 2023, and 84 were signed into law. These bills disproportionately targeted TGI youth and adults, particularly access to essential health care. The author indicates California must continue leading the nation to ensure that TGI people in California and across the country can access the health care and support services they need. The author asserts this bill will ensure that California provides comprehensive information and resources about access to trans-inclusive health care in the state, as TGI people and their families seek access to affirming health care and support.
2. BACKGROUND.
   1. Gender-Affirming Care and Recent Action in Other States. Gender-affirming care is considered safe, effective, and medically necessary by major professional health associations, such as the American Medical Association and American College of Obstetricians and Gynecologists (ACOG). Despite this, according to a 2023 report by the University of California, Los Angeles School of Law, Williams Institute, a growing number of states have taken action to restrict access to this care through proposed or enacted legislation or executive action. The report notes that since 2020, 36 states have attempted to restrict access to gender-affirming care, primarily through legislative action, and nine states have enacted legislative bans on gender-affirming care for youth and young adults.
      
   2. Particular Informational Challenges Related to Gender-Affirming Care. Human Rights Campaign, an LGBTQ+ civil rights organization that monitors state restrictions on gender-affirming care, has asserted that the debate on bills related to such care includes misconceptions and lies. In addition, according to ACOG, lack of awareness, knowledge, and sensitivity as well as bias from health care professionals contributes to inadequate access to, underuse of, and inequities within the health care system for transgender patients. Given these factors, it may be particularly challenging for individuals to identify reliable and trusted information on trans-inclusive health care and related protections.
      
   3. California Protections on Gender-Affirming Care. In recent years, California has enacted numerous laws protecting access to gender-affirming health care and protecting the providers offering such care. California agency interpretation by DMHC, California Department of Insurance, and DHCS has also generally been protective of individual’s access to gender-affirming health care as a medically necessary service for individuals covered by commercial insurance and Medi-Cal. This bill would create a web resource for this type of information. Although some similar resources exist online that address components of this bill’s requirements, the author and sponsor emphasize the importance of a state government website in combatting disinformation and providing people information they can trust. This bill is modeled on the website “abortion.ca.gov,” where individuals can seek reliable information about abortion services, a health care service that has also been the subject of debate and restricted in some states.
      
3. SUPPORT. Cosponsors Equality California, Planned Parenthood Affiliates of California, TransFamily Support Services, and TransYouth Liberation, along with other supporters, write that despite California’s strong laws protecting TGI people's access to essential health care, TGI people frequently have trouble finding affirming providers for routine care and identifying health care providers who offer gender-affirming care within their health plan can be even harder. Additionally, TGI individuals often feel unsure about the steps to obtaining care as well as feeling unsure about requirements that may need to be met for care. Supporters explain these access issues exacerbate existing health disparities among TGI Californians, who are more likely to experience chronic health conditions and experience higher rates of health concerns related to HIV, substance use, mental illness, and sexual and physical violence. As attacks on the TGI community continue to escalate, supporters indicate California must take additional steps to be a nationwide leader in supporting TGI people and their families seeking essential health care.
4. RELATED LEGISLATION. SB 957 (Wiener) requires DPH to collect demographic data, including sexual orientation, gender identity (SOGI), and intersexuality data, from third parties on any forms or electronic data systems, unless prohibited by federal or state law. Adds SOGI to the information reported for the purpose of statewide or local immunization information systems. Requires DPH to prepare an annual report concerning SOGI data. SB 957 is pending in the Assembly Health Committee.
5. PREVIOUS LEGISLATION.
   1. SB 345 (Skinner), Chapter 260, Statutes of 2023, enacts various safeguards against the enforcement of other states’ laws that prohibit, criminalize, sanction, authorize civil liability against, or otherwise interfere with a person, provider, or other entity in California that offers reproductive health care services or gender-affirming health care services.
   2. AB 352 (Bauer-Kahan), Chapter 255, Statutes of 2023, requires businesses that store or maintain medical information to maintain security features to protect the privacy of patients’ medical records related to gender-affirming health care, abortion, and contraception.
   3. AB 571 (Petrie-Norris), Chapter 256, Statutes of 2023, prohibits insurers from refusing to provide professional liability coverage to health care providers or from imposing a surcharge on health care providers, because they offer abortion, contraception, or gender-affirming services.
   4. AB 1707 (Pacheco), Chapter 258, Statutes of 2023, protects licensed health care professionals, clinics, and health facilities from being denied a license or subjected to discipline on the basis of a civil judgment, criminal conviction, or disciplinary action imposed by another state based solely on the application of a law that interferes with a person's right to receive services, including gender-affirming care, that would be lawful in California.
   5. SB 923 (Wiener), Chapter 822, Statutes of 2022, requires health plans and insurers to require all of their support staff in direct contact with enrollees or insureds, to complete evidence-based cultural competency training for the purpose of providing trans-inclusive health care for individuals who identify as TGI. Adds processes to continuing medical education requirements related to cultural and linguistic competency for physicians and surgeons specific to gender-affirming care services, as specified.
   6. SB 107 (Wiener), Chapter 810, Statutes of 2022, enacts various safeguards against the enforcement of other states’ laws that purport to penalize individuals from obtaining gender-affirming care that is legal in California.
   7. SB 1142 (Caballero), Chapter 566, Statutes of 2022, created abortion.ca.gov for resources for abortion services.
      
   8. AB 2218 (Santiago), Chapter 181, Statutes of 2020, establishes the Transgender Wellness Equity Fund (now the TGI Equity Fund), for the purpose of funding grants to organizations serving people that identify as TGI, to create or fund TGI-specific housing programs and partnerships with hospitals, health care clinics, and other medical providers to provide TGI-focused health care, as defined, and related education programs for health care providers.
      
6. DOUBLE REFERRAL. This bill is double referred. Upon passage of this Committee, it will be referred to the Judiciary Committee.
7. POLICY COMMENT. While this bill would provide a valuable informational resource, some of the required elements of this website are well beyond the scope of trans-inclusive health care. Some of the other issues, including, for example, programs and services for those experiencing or at risk of homelessness, are addressed by other agencies and entities. Although a truly comprehensive state resource may be helpful to some individuals, the author may also wish to consider narrowing the focus to what appears to be the core priority of the bill: providing a resource with information specific to trans-inclusive health care and related services. This would reduce the one-time and ongoing administrative resources required to produce and update a wide variety of information that is outside of the health-related agencies’ expertise.
   

REGISTERED SUPPORT / OPPOSITION:

Support

Equality California (cosponsor)

Planned Parenthood Affiliates of California (cosponsor)

Transfamily Support Services (cosponsor)

Transyouth Liberation (cosponsor)

Office of Lieutenant Governor Eleni Kounalakis

Access Support Network

American College of Obstetricians and Gynecologists, District IX

APLA Health

Asian Americans Advancing Justice Southern California

Bienestar Human Services

California Faculty Association

California Federation of Teachers AFL-CIO

California Legislative LGBTQ Caucus

California Transcends

Central California LGBTQ + Collaborative

Children Now

Courage California

El/la Para Translatinas

Essential Access Health

Faculty Association of California Community Colleges

Glide

Justice in Aging

Los Angeles LGBT Center

Mental Health America of California

Our Family Coalition

Parivar Bay Area

San Francisco Marin Medical Society

San Joaquin Pride Center

Sharp Healthcare

Somos Familia Valle

The Center for Sexuality & Gender Diversity

The Trevor Project

Transgender Health and Wellness Center

Transgender Resource, Advocacy & Network Service

Opposition

None on file.

Analysis Prepared by: Lisa Murawski / HEALTH / (916) 319-2097

 THIRD READING  

Bill No: SB 959

Author: Menjivar (D), et al.

Amended: 5/16/24

Vote: 21

SENATE HEALTH COMMITTEE: 8-1, 4/3/24

AYES: Roth, Gonzalez, Hurtado, Limón, Menjivar, Rubio, Smallwood-Cuevas, Wiener

NOES: Nguyen

NO VOTE RECORDED: Glazer, Grove

SENATE APPROPRIATIONS COMMITTEE: 5-2, 5/16/24

AYES: Caballero, Ashby, Becker, Bradford, Wahab

NOES: Jones, Seyarto

SUBJECT: Trans-inclusive care: resources and support services

SOURCE: California Legislative LGBTQ Caucus (co-sponsor)

Equality California (co-sponsor)

Planned Parenthood Affiliates of California (co-sponsor)

Transfamily Support Services (co-sponsor)

TransYouth Liberation (co-sponsor)

DIGEST:

Requires the California Health and Human Services Agency to establish a website where the public can access specified information about trans-inclusive health care and other support services in the state.

ANALYSIS

Existing law:

1. Establishes the California Health and Human Services Agency (CHHS), which consists of the following departments: Aging, Community Services and Development, Developmental Services, Health Care Services (DHCS), Managed Health Care (DMHC), Public Health (CDPH), Rehabilitation, Social Services, and State Hospitals. [GOV §12803, §12806]
2. Requires CHHS to convene a working group of representatives of the transgender, gender diverse, or intersex (TGI) community and the following state agencies to develop a quality standard for patient experience related to the TGI community and to recommend training curriculum to provide trans-inclusive health care: DMHC, DHCS, CDPH, California Department of Insurance (CDI), the California Health Benefit Exchange (Covered California), and CalPERS. [HSC §150950]
3. Requires CDPH’s Office of Health Equity to administer the TGI Wellness and Equity Fund for purposes of funding grants to create programs, or funding existing programs, focused on coordinating trans-inclusive health care for individuals who identify as TGI. [HSC §150900]
4. Defines “trans-inclusive health care” as comprehensive health care that is consistent with the standards of care for individuals who identify as TGI, honors an individual’s personal bodily autonomy, does not make assumptions about an individual’s gender, accepts gender fluidity and nontraditional gender presentation, and treats everyone with compassion, understanding, and respect. [WIC §14197.09]
5. Defines “gender-affirming health care” as medically necessary health care that respects the gender identity of the patient, as experienced and defined by the patient, and may include, but is not limited to, interventions to suppress the development of endogenous secondary sex characteristics; interventions to align the patient’s appearance or physical body with the patient’s gender identity; and, interventions to alleviate symptoms of clinically significant distress resulting from gender dysphoria. [WIC §16010.2]
6. Defines “gender-affirming mental health care” as mental health care or behavioral health care that respects the gender identity of the patient, as experienced and defined by the patient, and may include, but is not limited to, developmentally appropriate exploration and integration of identity, reduction of distress, adaptive coping, and strategies to increase family acceptance. [WIC §16010.2]

This bill:

1. Requires CHHS, or an entity it designates, to establish a website where the public can access information and resources to support TGI individuals and their families in accessing trans-inclusive health care and other support services in the state. Defines TGI as transgender, gender diverse, or intersex.
2. Requires the website to include the following information and resources:
3. Existing federal and state protections for TGI individuals in accessing trans-inclusive health care;
4. Existing federal and state protections for health care providers providing gender-afffirming health or mental health care against criminal or civil penalties, or for professional discipline based solely on the application of another state’s law that prohibits care that is lawful if provided in this state;
5. Information on how to access health care plans, Medi-Cal managed care plans, and health insurer directories that identify in-network providers that offer gender-affirming services, as required in existing state law;
6. Support services to assist an individual in accessing trans-inclusive health care, including, but not limited to, transportation, family engagement support, training and education sessions, and translation services;
7. Payment support resources available to assist individuals with health care costs, including coverage options, state programs, and other available assistance;
8. General description of trans-inclusive health care, including gender-affirming health care and gender-affirming mental health care;
9. Information to combat misinformation and disinformation about trans-inclusive health care, including gender-affirming health care and gender-affirming mental health care;
10. References and links to additional related information and resources for TGI individuals and their families regarding the following, to the extent such information is available to the agency:
11. Legal protections for TGI individuals to access health care, housing, employment, public accommodations, and other programs;
12. Filing a complaint with the appropriate government agency following a violation of an individual’s rights;

iii) Accessing legal services;

iv) Resources for victims of hate incidents and hate crimes;

v)  Updating an individual’s name and gender marker on state and federal identification records, including, but not limited to, driver’s licenses, birth certificates, death certificates, passports, and social security cards;

vi) Programs and services for those experiencing, or at risk of experiencing, homelessness; and,

vii) Programs and services to promote economic security, including food and cash assistance programs.

i)   Any other information or resources that will assist an individual seeking comprehensive and accurate information about accessing trans-inclusive health care and other support services in the state.

1. Requires CHHS to consult with subject matter experts and the Department of Justice when determining the information and resources to be posted. Specifies that “subject matter experts” include, but are not limited to, representatives from TGI communities, including Black, Indigenous, and people of color and may include the entities and individuals that participated in the TGI Health Care Quality Standards and Training Curriculum Working Group as established in state law, which includes representatives of the state health departments, TGI-serving organizations, TGI individuals, and health care providers, and the Civil Rights Department.
2. Requires the website to have mobile capabilities and to comply with federal and state laws governing the accessibility of state websites. Requires the website and informational materials created or distributed pursuant to this bill to be accessible to all state residents and translated into Spanish, Chinese, Tagalog, Vietnamese, and Korean and in compliance with the Dymally-Alatorre Bilingual Services Act.
3. Prohibits the inclusion of the name or location of any individual who is a provider of gender-affirming services on the website.
4. Requires CHHS, in consultation with subject matter experts, to review the information and resources on the internet website to ensure that it is current and updated at least once every year. Requires the website to contain a feature to allow users to report erroneous or outdated information. Permits CHHS to consult with the Department of Justice as necessary.
5. Permits CHHS to accept donations to support and maintain the website. Such accepted donations shall be available upon appropriation by the Legislature for the purpose of supporting and maintaining the website.

COMMENTS:

1. Author’s statement. According to the author:

TGI people, especially TGI youth, are confronting an alarming rise in discrimination and violence, fueled by misinformation and political attacks. According to the ACLU, over 500 anti-LGBTQ+ bills were introduced in 2023 in more than 40 states, and 84 were signed into law. These bills disproportionately targeted TGI youth and adults, particularly access to health care. The Williams Institute at the UCLA School of Law estimates that about one-third of transgender youth in the U.S. now live in states that ban access to gender-affirming care. California must continue leading the nation to ensure that TGI people in California and across the country can access the health care and support services they need. This bill will ensure that as TGI people and their families seek access to affirming health care and support, California provides comprehensive information and resources about access to trans-inclusive health care in the state. This bill will establish an online resource for TGI people and their families to combat misinformation and provide accurate information about access to trans-inclusive health care, existing legal protections for patients and health care providers, and other available support services.

1. TGI access to health care. In October 2017, the UCLA Center for Health Policy Research and the Williams Institute published a report on the demographics, health, and health care access among transgender adults in California who participated in the 2015-2016 California Health Interview Survey (CHIS). According to the report, transgender adults in California experience disparities in mental health, disability status, and health care access. A 2024 national survey by the National Center for Transgender Equity, which included responses from people identifying as transgender or nonbinary, as well as a small number of people who indicated they were born with a variation in physical sex characteristics including intersex variation, found that of the 28% who did not see a doctor when they needed to in the past 12 months, 24% did not go due to fear of mistreatment. Of those that did see a doctor in the past 12 months, 48% reported having at least one negative experience because they were transgender, such as being refused health care, being misgendered, having a provider use harsh or abusive language when treating them, or having a provider be physically rough or abusive when treating them. Just over a quarter reported having had at least one issue with their insurance company in the last 12 months, such as being denied coverage for hormone therapy, surgery, or another type of health care related to their gender identity/transition; gender-specific health care or routine health care, because they were transgender.
2. Restrictions on gender-affirming care for youth in other states. According to a 2023 report by the Williams Institute, despite the fact that gender-affirming care is considered safe, effective, and medically necessary by major professional health associations, a growing number of states have taken action to restrict youth access to this care through proposed or enacted legislation or executive action. Legislation that limits access to gender-affirming health care for minors include criminal penalties against health professionals and parents who provide or enable access to such care. As of March 2023, an estimated 156,500 transgender youth live in 32 states where access to gender-affirming care has been restricted or was at risk of being banned due to legislation filed that year. An estimated 146,300 transgender youth in 30 states have lost access to care or were at risk of losing access to care due to pending legislation.
3. California protections on gender-affirming care. In recent years, California has enacted numerous laws protecting access to gender-affirming health care and protecting the providers offering such care as discussed below in prior legislation. California agency interpretation by DMHC, CDI, and DMHC has also generally been protective of individual’s access to gender-affirming health care as a medically necessary service for individuals covered by commercial insurance and Medi-Cal. This bill creates a website where information about these rights can be found.

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

According to the Senate Appropriations Committee:

CHHS would likely designate the Department of Managed Health Care (DMHC) as responsible for developing and maintaining the website. Unknown ongoing costs for the DMHC, likely low hundreds of thousands (Managed Care Fund).

SUPPORT: (Verified 5/16/24)

California Legislative LGBTQ Caucus (co-sponsor)

Equality California (co-sponsor)

Planned Parenthood Affiliates of California (co-sponsor)

Transfamily Support Services (co-sponsor)

TransYouth Liberation (co-sponsor)

Access Support Network San Luis Obispo, Monterey, Santa Barbara, and San Benito Counties

American College of Obstetricians and Gynecologists District IX

APLA Health

Asian Americans Advancing Justice Southern California

Bienestar Human Services

California Faculty Association

California Federation of Teachers

California TRANScends

Central California LGBTQ+ Collaborative

Children Now

City of Alameda

County Health Executives Association of California

Courage California

El/La Para Translatinas

Essential Access Health

Faculty Association of California Community Colleges

GLIDE

Justice in Aging

Los Angeles LGBT Center

Mental Health America of California

Our Family Coalition

Parivar Bay Area

San Joaquin Pride Center

Sharp Healthcare

Somos Familia Valle

The Center for Sexuality & Gender Diversity

The Trevor Project

Transgender Health and Wellness Center

Transgender Resource, Advocacy, & Network Service

OPPOSITION: (Verified 5/16/24)

None received

ARGUMENTS IN SUPPORT: Co-sponsors Equality California, Planned Parenthood Affiliates of California, TransFamily Support Services, and TransYouth Liberation, along with other supporters, write:

Despite California’s strong laws protecting TGI people's access to essential health care, TGI people frequently have trouble finding affirming providers for routine care and identifying health care providers who offer gender-affirming care within their health plan can be even harder. Additionally, TGI individuals often feel unsure about the steps to obtaining care as well as feeling unsure about requirements that may need to be met for care. These access issues exacerbate existing health disparities among TGI Californians, who are more likely to experience chronic health conditions and experience higher rates of health concerns related to HIV, substance use, mental illness, and sexual and physical violence. As attacks on the TGI community continue to escalate, California must take additional steps to be a nationwide leader in supporting TGI people and their families seeking essential health care.

Prepared by: Jen Flory / HEALTH / (916) 651-4111

5/18/24 14:48:46

**** END ****

SENATE COMMITTEE ON APPROPRIATIONS

Senator Anna Caballero, Chair

2023 - 2024 Regular Session

SB 959 (Menjivar) - Trans-inclusive care: resources and support services

Bill Summary:

SB 959 would require the California Health and Human Services Agency (CHHS) to establish a website where the public can access specified information about trans-inclusive health care and other support services in the state.

*********** ANALYSIS ADDENDUM – SUSPENSE FILE ***********

The following information is revised to reflect amendments

adopted by the committee on May 16, 2024

Fiscal Impact:

CHHS would likely designate the Department of Managed Health Care (DMHC) as responsible for developing and maintaining the website. Unknown ongoing costs for the DMHC, likely low hundreds of thousands (Managed Care Fund).

Author Amendments:

Require the website to be updated annually rather than every 6 months.

Committee Amendments:

Permit CHHS to accept donations to support and maintain the website.

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SENATE COMMITTEE ON APPROPRIATIONS

Senator Anna Caballero, Chair

2023 - 2024 Regular Session

SB 959 (Menjivar) - Trans-inclusive care: resources and support services

Bill Summary:

SB 959 would require the California Health and Human Services Agency (CHHS) to establish a website where the public can access specified information about trans-inclusive health care and other support services in the state.

Fiscal Impact:

CHHS would likely designate the Department of Managed Health Care (DMHC) as responsible for developing and maintaining the website. The DMHC estimates the costs to be approximately $682,000 in 2025-26, $330,000 in 2026-27, $337,000 in 2027-28, $346,000 in 2028-29, and $354,000 in 2029-30 and annually thereafter (Managed Care Fund).

Background:

Current law requires the CHHS to convene a working group of representatives from at least three transgender, gender diverse, or intersex (TGI) serving organizations, at least three individual California residents who identify as TGI, health care providers, and one appointee representing each of the following state agencies: the Department of Managed Health Care, the Department of Insurance, the Department of Health Care Services, the California Health Benefit Exchange, CalPERS, and the Department of Public Health. The working group is charged with developing a quality standard for patient experience to measure cultural competency related to the TGI community and recommend training curriculum to provide trans-inclusive health care. Current law requires the quality standard and recommendations for curriculum to be developed no later than March 1, 2024.

Current law defines “trans-inclusive health care” as comprehensive health care that is consistent with the standards of care for individuals who identify as TGI, honors an individual’s personal bodily autonomy, does not make assumptions about an individual’s gender, accepts gender fluidity and nontraditional gender presentation, and treats everyone with compassion, understanding, and respect.

Proposed Law:

Specific provisions of the bill would:

• Require the CHHS, or an entity designated by the agency, to establish an internet website where the public can access information and resources to support TGI individuals and their families in accessing trans-inclusive health care and other support services in the state.
• Specify the information and resources to be included on the internet website.
• Require the CHHS, in developing and maintaining the internet website, to consult with subject matter experts, as specified.
• Require the internet website and informational materials to be translated into Spanish, Chinese, Tagalog, Vietnamese, and Korean and in compliance with the state’s Dymally-Alatorre Bilingual Services Act.

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SENATE COMMITTEE ON HEALTH

Senator Richard Roth, Chair

BILL NO: SB 959

SUBJECT: Trans-inclusive care: resources and support services

SUMMARY:

Requires the California Health and Human Services Agency to establish a website where the public can access specified information about trans-inclusive health care and other support services in the state.

Existing law:

1. Establishes the California Health and Human Services Agency (CHHS), which consists of the following departments: Aging, Community Services and Development, Developmental Services, Health Care Services (DHCS), Managed Health Care (DMHC), Public Health (CDPH), Rehabilitation, Social Services, and State Hospitals. [GOV §12803, §12806]
2. Requires CHHS to convene a working group of representatives of the transgender, gender diverse, or intersex (TGI) community and the following state agencies to develop a quality standard for patient experience related to the TGI community and to recommend training curriculum to provide trans-inclusive health care: DMHC, DHCS, CDPH, California Department of Insurance (CDI), the California Health Benefit Exchange (Covered California), and CalPERS. [HSC §150950]
3. Requires CDPH’s Office of Health Equity to administer the TGI Wellness and Equity Fund for purposes of funding grants to create programs, or funding existing programs, focused on coordinating trans-inclusive health care for individuals who identify as TGI. [HSC §150900]
4. Defines “trans-inclusive health care” as comprehensive health care that is consistent with the standards of care for individuals who identify as TGI, honors an individual’s personal bodily autonomy, does not make assumptions about an individual’s gender, accepts gender fluidity and nontraditional gender presentation, and treats everyone with compassion, understanding, and respect. [WIC §14197.09]
5. Defines “gender-affirming health care” as medically necessary health care that respects the gender identity of the patient, as experienced and defined by the patient, and may include, but is not limited to, interventions to suppress the development of endogenous secondary sex characteristics; interventions to align the patient’s appearance or physical body with the patient’s gender identity; and, interventions to alleviate symptoms of clinically significant distress resulting from gender dysphoria. [WIC §16010.2]
6. Defines “gender-affirming mental health care” as mental health care or behavioral health care that respects the gender identity of the patient, as experienced and defined by the patient, and may include, but is not limited to, developmentally appropriate exploration and integration of identity, reduction of distress, adaptive coping, and strategies to increase family acceptance. [WIC §16010.2]

This bill:

1. Requires CHHS, or an entity it designates, to establish a website where the public can access information and resources to support TGI individuals and their families in accessing trans-inclusive health care and other support services in the state. Defines TGI as transgender, gender diverse, or intersex.
2. Requires the website to include the following information and resources:
3. Existing federal and state protections for TGI individuals in accessing trans-inclusive health care;
4. Existing federal and state protections for health care providers against criminal or civil penalties, or for professional discipline based solely on the application of another state’s law that prohibits care that is lawful if provided in this state;
5. Information on how to access health care plans, Medi-Cal managed care plans, and health insurer directories that identify in-network providers that offer gender-affirming services, as required in existing state law;
6. Support services to assist an individual in accessing trans-inclusive health care, including, but not limited to, transportation, family engagement support, training and education sessions, and translation services;
7. Payment support resources available to assist individuals with health care costs, including coverage options, state programs, and other available assistance;
8. General description of trans-inclusive health care, including gender-affirming health care and gender-affirming mental health care;
9. Information to combat misinformation and disinformation about trans-inclusive health care, including gender-affirming health care and gender-affirming mental health care;
10. References and links to additional related information and resources for TGI individuals and their families regarding the following:
11. Legal protections for TGI individuals to access health care, housing, employment, public accommodations, and other programs;
12. Filing a complaint with the appropriate government agency following a violation of an individual’s rights;

iii) Accessing legal services;

iv) Resources for victims of hate incidents and hate crimes;

v)  Updating an individual’s name and gender marker on state and federal identification records, including, but not limited to, driver’s licenses, birth certificates, death certificates, passports, and social security cards;

vi) Programs and services for those experiencing, or at risk of experiencing, homelessness; and,

vii) Programs and services to promote economic security, including food and cash assistance programs.

i)   Any other information or resources that will assist an individual seeking comprehensive and accurate information about accessing trans-inclusive health care and other support services in the state.

1. Requires CHHS to consult with subject matter experts and the Department of Justice when determining the information and resources to be posted. Specifies that “subject matter experts” include, but are not limited to, representatives from TGI communities, including Black, Indigenous, and people of color and may include the entities and individuals that participated in the TGI Health Care Quality Standards and Training Curriculum Working Group as established in state law, which includes representatives of the state health departments, TGI-serving organizations, TGI individuals, and health care providers.
2. Requires the website to have mobile capabilities and to comply with federal and state laws governing the accessibility of state websites. Requires the website and informational materials created or distributed pursuant to this bill to be accessible to all state residents and translated into Spanish, Chinese, Tagalog, Vietnamese, and Korean and in compliance with the Dymally-Alatorre Bilingual Services Act.
3. Prohibits the inclusion of the name or location of any individual who is a provider of gender-affirming services on the website.
4. Requires CHHS, in consultation with subject matter experts, to review the information and resources on the internet website to ensure that it is current and updated at least once every six months. Requires the website to contain a feature to allow users to report erroneous or outdated information. Permits CHHS to consult with the Department of Justice as necessary.

FISCAL EFFECT:

This bill has not been analyzed by a fiscal committee.

COMMENTS:

1. Author’s statement. According to the author, TGI people, especially TGI youth, are confronting an alarming rise in discrimination and violence, fueled by misinformation and political attacks. According to the ACLU, over 500 anti-LGBTQ+ bills were introduced in 2023 in more than 40 states, and 84 were signed into law. These bills disproportionately targeted TGI youth and adults, particularly access to health care. The Williams Institute at the UCLA School of Law estimates that about one-third of transgender youth in the U.S. now live in states that ban access to gender-affirming care. California must continue leading the nation to ensure that TGI people in California and across the country can access the health care and support services they need. This bill will ensure that as TGI people and their families seek access to affirming health care and support, California provides comprehensive information and resources about access to trans-inclusive health care in the state. This bill will establish an online resource for TGI people and their families to combat misinformation and provide accurate information about access to trans-inclusive health care, existing legal protections for patients and health care providers, and other available support services.
2. TGI access to health care. In October 2017, the UCLA Center for Health Policy Research and the Williams Institute published a report on the demographics, health, and health care access among transgender adults in California who participated in the 2015-2016 California Health Interview Survey (CHIS). According to the report, transgender adults in California experience disparities in mental health, disability status, and health care access. A 2024 national survey by the National Center for Transgender Equity, which included responses from people identifying as transgender or nonbinary, as well as a small number of people who indicated they were born with a variation in physical sex characteristics including intersex variation, found that of the 28% who did not see a doctor when they needed to in the past 12 months, 24% did not go due to fear of mistreatment. Of those that did see a doctor in the past 12 months, 48% reported having at least one negative experience because they were transgender, such as being refused health care, being misgendered, having a provider use harsh or abusive language when treating them, or having a provider be physically rough or abusive when treating them. Just over a quarter reported having had at least one issue with their insurance company in the last 12 months, such as being denied coverage for hormone therapy, surgery, or another type of health care related to their gender identity/transition; gender-specific health care or routine health care, because they were transgender.
3. Restrictions on gender-affirming care for youth in other states. According to a 2023 report by the Williams Institute, despite the fact that gender-affirming care is considered safe, effective, and medically necessary by major professional health associations, a growing number of states have taken action to restrict youth access to this care through proposed or enacted legislation or executive action. Legislation that limits access to gender-affirming health care for minors include criminal penalties against health professionals and parents who provide or enable access to such care. As of March 2023, an estimated 156,500 transgender youth live in 32 states where access to gender-affirming care has been restricted or was at risk of being banned due to legislation filed that year. An estimated 146,300 transgender youth in 30 states have lost access to care or were at risk of losing access to care due to pending legislation.
4. California protections on gender-affirming care. In recent years, California has enacted numerous laws protecting access to gender-affirming health care and protecting the providers offering such care as discussed below in prior legislation. California agency interpretation by DMHC, CDI, and DMHC has also generally been protective of individual’s access to gender-affirming health care as a medically necessary service for individuals covered by commercial insurance and Medi-Cal. This bill creates a website where information about these rights can be found.
5. Related legislation. SB 957 (Wiener) requires CDPH to collect demographic data, including sexual orientation, gender identity (SOGI), and intersexuality data, from third parties on any forms or electronic data systems, unless prohibited by federal or state law. Adds SOGI to the information reported for the purpose of statewide or local immunization information systems. Requires CDPH to prepare an annual report concerning SOGI data.
6. Prior legislation. SB 345 (Skinner, Chapter 260, Statutes of 2023) enacts various safeguards against the enforcement of other states’ laws that prohibit, criminalize, sanction, authorize civil liability against, or otherwise interfere with a person, provider, or other entity in California that offers reproductive health care services or gender-affirming health care services.

SB 923 (Wiener, Chapter 822, Statutes of 2022) requires health plans and insurers to require all of their support staff in direct contact with enrollees or insureds, to complete evidence-based cultural competency training for the purpose of providing trans-inclusive health care for individuals who identify as TGI. Adds processes to continuing medical education requirements related to cultural and linguistic competency for physicians and surgeons specific to gender-affirming care services, as specified.

SB 107 (Wiener, Chapter 810, Statutes of 2022) enacts various safeguards against the enforcement of other states’ laws that purport to penalize individuals from obtaining gender-affirming care that is legal in California.

SB 1142 (Caballero, Chapter 566, Statutes of 2022) created abortion.ca.gov for resources for abortion services. This bill models many of its provisions.

AB 352 (Bauer-Kahan, Chapter 255, Statutes of 2023) requires businesses that store or maintain medical information to maintain security features to protect the privacy of patients’ medical records related to gender-affirming health care, abortion, and contraception.

AB 571 (Petrie-Norris, Chapter 256, Statutes of 2023) prohibits insurers from refusing to provide professional liability coverage to health care providers or from imposing a surcharge on health care providers, because they offer abortion, contraception, or gender-affirming services.

AB 1707 (Pacheco, Chapter 258, Statutes of 2023) protects licensed health care professionals, clinics, and health facilities from being denied a license or subjected to discipline on the basis of a civil judgment, criminal conviction, or disciplinary action imposed by another state based solely on the application of a law that interferes with a person's right to receive services, including gender-affirming care, that would be lawful in California.

AB 2218 (Santiago, Chapter 181, Statutes of 2020) establishes the Transgender Wellness Equity Fund (now the TGI Equity Fund), for the purpose of funding grants to organizations serving people that identify as TGI, to create or fund TGI-specific housing programs and partnerships with hospitals, health care clinics, and other medical providers to provide TGI-focused health care, as defined, and related education programs for health care providers.

1. Support. Co-sponsors Equality California, Planned Parenthood Affiliates of California, TransFamily Support Services, and TransYouth Liberation, along with other supporters, write that despite California’s strong laws protecting TGI people's access to essential health care, TGI people frequently have trouble finding affirming providers for routine care and identifying health care providers who offer gender-affirming care within their health plan can be even harder. Additionally, TGI individuals often feel unsure about the steps to obtaining care as well as feeling unsure about requirements that may need to be met for care. These access issues exacerbate existing health disparities among TGI Californians, who are more likely to experience chronic health conditions and experience higher rates of health concerns related to HIV, substance use, mental illness, and sexual and physical violence. As attacks on the TGI community continue to escalate, California must take additional steps to be a nationwide leader in supporting TGI people and their families seeking essential health care.
2. Policy Comment. While this bill models itself after a similar bill that created a state website for information regarding abortion services, some of the required elements of this website are beyond the scope of trans-inclusive health care. The language requires that the website also contain references and links on topics such as hate crimes, economic security, including food and cash assistance, programs and services for those experiencing or at risk of homelessness, and any other information or resources about other support services in the state. Although these additional resources may presumably be created by other organizations or agencies, this may make creating and updating the website unwieldy, and the subject matter experts identified do not have expertise in all of these areas.
3. Amendments. The author and committee have agreed to the following amendments:
   1. Clarify that the information regarding provider federal and state protections against criminal or civil penalties or professional discipline be limited to such information as it relates to gender-affirming health or mental health care. As written, it could be interpreted to include other unrelated information about professional discipline or provider liability.
   2. Include the California Civil Rights Department as a potential subject matter expert to be consulted in the development of the website. The Civil Rights Department’s jurisdiction includes investigating complaints of discrimination at business establishments, which includes health care providers.
   3. Reduce the requirement to review the website content from every six months to annually so as to not overly burden CHHS or the subject matter experts, who may not be compensated for their efforts.
   4. Limited the required information about subjects not related to trans-inclusive healthcare to just that information that is available to CHHS.

SUPPORT AND OPPOSITION:

Support: Equality California (co-sponsor)

Planned Parenthood Affiliates of California (co-sponsor)

Transfamily Support Services (co-sponsor)

TransYouth Liberation (co-sponsor)

Access Support Network

American College of Obstetricians and Gynecologists District IX

APLA Health

Asian Americans Advancing Justice Southern California

Bienestar Human Services

California Federation of Teachers

Central California LGBTQ+ Collaborative

Children Now

Courage California

El/La Para Translatinas

Essential Access Health

Faculty Association of California Community Colleges

Glide

Justice in Aging

Los Angeles LGBT Center

Mental Health America of California

Our Family Coalition

Sharp Healthcare

The Center for Sexuality & Gender Diversity

The Trevor Project

Transgender Health and Wellness Center

Transgender Resource, Advocacy, & Network Service

Oppose: None received

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