Senate Standing Committee on Health

You start this informational hearing, letting Members know we're starting. We're not taking a vote, so we don't need to take a quorum and just repeat. I understand there is some confusion about the room number. It is room 1200 in the swing space. We are in 1200 in the swing space. Good afternoon everybody and thanks for being here. As you know, this is the first Senate informational hearing dealing with the redo of the MHSA.

This Bill will start legislatively in the Assembly, but the Senate wanted to get a chance to be able to talk about it a little bit and let all of our Members get some eyes on it before we start. I'm sure the staff wrote me up talking points, but I'm just going to talk. So we thank you all for being here today and being a part of it.

This has been a long time in coming and I want to thank everybody who had anything to do with pulling this together. I also want to thank healthcare staff Rayes Diaz for the very fine background paper he prepared for us all. Kind of lays out a lot of the history.

I will say somebody pointed out to me the one piece of history that wasn't involved was Rose King who was also very involved in the beginning of this and a huge advocate who lost her life not too long ago. So we also want to make sure she's mentioned in this and I think some of the criticism she levied at the time and through the years, we are now beginning to really address at a much deeper level.

So as everyone knows, we have a crisis on our hands with our world of mental health. And as everyone knows, 20 years ago we passed the MHSA Prop 63 to really redefine how we do mental health services. The great leadership of Mayor Dale Steinberg and Mr. CZ at the time and then Rose King, and then through the implementation, it was meant to be focused on the sick of people who had struggled with the most.

As we know, after the closure of the state hospitals, a lot of promises were made about ongoing supports which never materialized. This was a huge attempt and has done a lot of good things, unfortunately, just because every county does it a little bit differently. We've had trouble having some standardizations with data issues and by all appearances just needing to walk outside in any city in California.

You can see the impact of the increasing amount of people with serious and persistent mental health issues and or substance abuse issues and their housing on our streets, corners and alleyways, which isn't good for anybody. So over the years, folks know we've been doing a lot of work on this space and this then will really form a cornerstone of that work going forward. Huge thank to the Governor and Administration.

It can't be said enough that there is no Governor who has made mental health issues a priority as this Governor has and for that we have a lot to be grateful for. So today we're talking about kind of the redesign of the Mental Health Services Act and the buckets and the way the money is being spent and allocated.

And it is true we are reprioritizing those who suffer the most in the systems and we are also making the state a lot more responsible and making sure that we don't do things different in every county while providing for flexibility that we're able to measure and standardize things a little bit more so things can be scaled.

So some of the great innovations that we've come up with can then be implemented and used in other parts of the system and we don't have to keep recreating the wheel. So we appreciate the administrations and engagement with us and as we continue to work together to get to the finish line of this it really takes everybody doing this kind of work. So we appreciate all of that. And with that I'd ask any of my colleagues if they'd like to make any opening comments. Seeing none.

We're going to go ahead and invite Dr. Mark Ghaly, the secretary of the health and human services agency and Michelle Baass to come forward. Sit here at our fine table that we're having people back at join us in this conversation and be able to walk us all through the changes that we see before us today in more detail. All right. Welcome.

Good afternoon. Thank you for inviting us including us in this important day on behalf of Michelle and myself. Really appreciate the chance to be in front of the committee and Senator Eggman for your leadership. Today represents another key milestone in California's journey to build a person centered, whole person focused, equity anchored behavioral health system that's accessible to all who need it, when they need it and where they need it.

Today's discussion about reforming the MHSA is about how to strengthen a key pillar that has been an anchor of our system for a long time. Not so that it only plugs the holes and fills the gaps but that it bolts together some of these other really important pieces of our behavioral health transformation that Director Boss's Department and other departments within California Health and Human Services Agency and other agencies in California are putting together. We're starting to see the fruits of some of those programs today.

MHSA represents today three out of every $10 roughly of public behavioral health dollars. That isn't enough to buoy up the entire system but it's too important to continue to overlook its impact by loose and weak accountability structures, oversight structures.

So today is one of the key priorities, as you already said, Senator Eggman, is to make sure that we can understand what those dollars are being used for how they're impacting Californians in need today and how we're building the kind of system that we want in the future. A lot has changed in 20 years since MHSA was first passed. We have the benefits of the Affordable Care Act. We've talked about that previously.

To allow millions, literally millions of Californians who didn't have coverage before to have coverage today through Medicaid or covered California to really increase the availability of behavioral health services that are part of Medicaid. To start conversations about what the health plans roles are, not just county behavioral health and providing those for those with the most severe conditions, but what about those with the mild to moderate conditions?

I applaud Director Baass and her team's efforts in the last year to up the ante for health plans to do more, to be more focused on behavioral health through their new contracts. And these are important aspects that build upon the Children Youth Behavioral Health Initiative, the investments in the Department of State Hospital and our IST population, building up the infrastructure through Bchip and the community care expansion approaches at Department of Social Services.

All meant to come together to help support this broad tapestry, if you will, of a plan to really improve behavioral health for all Californians. But within that, and we had these conversations last year in the discussions of Care Act and this new pathway that's being unleashed in California in eight counties this year, seven in October, then LA.

At the end of the year, that really require us to have a new approach for those who often fall through the cracks that hit the pavement, literally because of some of the holes in our safety net system and suffer the most. We've talked about how often we wait for those individuals to encounter law enforcement or the most severe parts of our systems before they get help.

That care pathway in some ways is supported by the change that we've been talking about over the last many months, frankly, many years with stakeholders, legislators, advocates, you name them through letters and conversations to really change our approach.

And we've used the word often modernize our Behavioral Health Services Act to include things like substance use disorders to make sure that housing, which hasn't always been seen as one of the key services, is not just seen as a service, but prioritized as the thing that might matter the most for people who are suffering with the most severe disorders in our communities. Because of your leadership, Senator Egman, and the governor's, I'd say expansive, broad vision.

We stand here today with a fresh set of amendments in print just last night, which some people have said, oh, I see, we've compromised. I'm going to challenge that premise all day long. Compromise means I wanted three, you wanted one. We settled at two. Neither of us really got what we wanted. In my view, the amendments that crossed recently in print this morning represent improvements to the proposal.

They do things that, for whatever reason, weren't part of that first set of proposed changes to the Behavioral Health Services Act. They help us move forward with some of the key things that have evaded lawmakers and proponents of change for the MHSA for quite some time. For example, county flexibility. I know the counties I've had the privilege of working at before coming to Sacramento that we felt restricted by, "Hey, Dollars in this bucket. What about this bucket? We need a little bit more over here."

How do we allow for that change? The proposed amendment to allow in the first planning cycle, up to 7% of any one bucket to move across to a different bucket.

Total of 14% provides that kind of flexibility that allows the framework of the Behavioral Health Services Act to be maintained while providing that unique aspect county by county to have us recognize fully that California isn't one California that we have north and south, coastal and inland, central, all the different unique characteristics of what we need in California can be covered there. We also proposed changes to how we're looking at prevention.

Originally in the original proposal, it was proposed to have a standalone 5% prevention bucket for population based prevention. Too long we conflated early intervention with prevention and in the first proposal it was determined, hey, let's have a 5% prevention bucket, hearing lots of feedback considering how to make 5% go as far as possible in statewide population prevention approaches.

The suggestion is to move that 5%, turn it into a 4% bucket and have it run through the State's Department of Public Health, California Department of Public Health with collaboration with the Oversight and Accountability Commission as well as the Department of Healthcare services to make sure that we're able to touch, in many ways, the broad population prevention needs that this state not only needs, but deserves to stay in front of some of the most emerging issues by moving that 4% up to the state level.

We have now three remaining local buckets. The housing intervention bucket at 30%, the Full Service Partnership bucket at 35%, and a Behavioral Health Services and Support bucket that includes early intervention at 35%. Another set of amendments which I think really reinforce California's commitment to young people.

The recognition that young people have unique needs, that being able to get in front of some of those earliest signs and symptoms, some of those important antistigma breakdown barriers, conversations around prevention, normalizing conversations around mental health, substance use disorder, important for young people. That both within our early intervention allocations and our prevention allocations, to say that 51% of those dollars are focused on young people and maintaining hard earned gains over, frankly, not just years but decades.

To advocate within current MHSA regulation, to build that now into statute, and to continue that important work we also have within the behavioral health services and support buckets allowed some additional allowances that people said were missing. This again makes improvements to the plan and the proposal to allow outreach and engagement activities, which are critical to be funded through the Behavioral Health Services and Support bucket, I think, is something that certainly was overlooked initially, but we think is really key and important.

And when you think about other upcoming changes and additions to our broad tapestry, if you will, of Behavioral Health Resources Director Boss's work with her Department on advancing the BH Connect proposal is opening up the doors to a whole nother set of services and resources available to counties, of which outreach and engagement will be highlighted. We also recognize that certain smaller counties need flexibility, maybe even earlier than larger counties.

In addition to some of those broad bucket flexibilities, allowing smaller counties to receive some additional ability to invest in capital for housing earlier in the process will allow us to make sure that we're not leaving resources locked up in some ways, held hostage to our rules, and allowing those to be more flexible and used in a better way. We also adjusted the definition to chronically homeless. We heard loud and clear. Frankly, we should have implemented this early on.

We know historically that the federal definition of chronically homeless sometimes leaves out people that California has always prioritized and sought to serve with our housing resources.

So allowing the Department of Healthcare Services to define chronically homeless in a way that meets California's needs, I think, creates the flexibility and not just allows us, but forces us not to continue to overlook some individuals who get some level of service and then suddenly find out because they were temporarily housed or even incarcerated, that they're ineligible for those federally supported services. We spent a lot of time in the original proposal talking about how we're focused on accountability, transparency, and oversight.

I want to reemphasize the focus on the three year plan and the robustness of that plan. The requirement that counties bring together a whole set of stakeholders that aren't always at the table in the three year planning process, that it's data driven, that they're using the data that is unique to their counties, that has a statewide lens to make those plans, but in that we're allowing substance use disorders alone. Thank you, Senator Eggman.

For bills in past years that allowed us to recognize co occurring disorders as allowable use for MHSA funding. In the Behavioral Health Services Act proposal, we're allowing counties based on data driven by the evidence, driven by the voices at the table, to prioritize programs that are just focused on substance use disorder. Not a requirement per se, but driven by the data.

There isn't almost a county I can imagine in California that isn't going to have some compelling data and voice at the table to start to invest some of these dollars in substance use disorder services alone. We hope that that happens in an integrated way. We're going to push that it happens in an integrated way. And I'm not just talking about integration of mental health and substance use disorder services. But I started with a whole person focus that means health as well. So all three coming together.

We've also had quite a bit of conversation about our ongoing support and relationship with the Oversight and Accountability Commission. I'm proud of some of the conversations we've had to date in the last many weeks about how we use the breadth of talent, the breadth of energy, and frankly, person power to push us, not just in the realm of oversight and accountability. What is the plan? Did the plan come to fruition? Absolutely part of it. Doing that transparently, but providing really critical technical assistance.

None of us today have the skill set yet to do what we need to do to realize a system tomorrow, whether it's data systems or just the chops to get it done on the Medicaid billing side. So being able to work together with the OAC to advance a united front around supporting these skills to proliferate around California and support counties and other partners, I think is a key piece that through consultation and advisement between the Department of Healthcare Services, the OAC.

And in the case of Prevention CDPH, making sure that we choose outcomes and metrics that make sense for California as a whole and allow the support of the county data to build those plans locally. I'm looking forward to those ongoing conversations and over months and years to come to build that stronger partnership.

We also provided clarification and heard this loud and clear that we needed to be certain that through this reform we weren't pulling in the kitchen sink, that we weren't requiring counties to say every penny of realignment, every penny from this other bucket that has unique and important needs is spent on those other needs as well. Clarifying that this needs to be done with the funds that we have with the aye to leverage them as much as possible.

We have had conversations with some individual counties in larger groups recognizing that today some services that we fully fund with MHSA dollars could actually leverage additional Medicaid dollars. And that's a benefit. That's one of the most important aspects of our transformation over the past two decades, that we want to make sure that we leverage more and more. It's going to take bandwidth, it's going to take technical assistance, but we have a strong belief that that is going to help us take our scarce resources.

As plentiful as they might seem, they're never enough to do everything we want. So how do we continue to make them go as far as humanly possible? I think those are the most important aspects of the proposed amendments. But I want to return to something you said, Senator, the transformations.

Although we want to I often talk about we want to raise all boats, but frankly, some more than others, the boat we want to raise the most are those who we've so often overlooked and allowed to live with. The most severe conditions and some of the hardest conditions in California. And we've had very robust, meaningful conversations on how best to do that. And changing the funding categories alone does not assure that, but it does help us take one important step.

So this change, this transformation, this modernization, taken into context of all the other changes that this Legislature, this Governor, his Administration have advanced, I think give us a real hope and chance to put something together that we can soon enough look back at and be really proud as we walk out our door and our offices to see improvement and change not just in the streets and where we might drive by an encampment but when our kids come home from school when they're having their conversations with their friends, that we know that some of the things impacting all Californians are part of this transformation of today. So thank you for your time.

Thank you, Dr. Kelly. I think we'll just go to Director Baass before we take questions sure.

Here just to answer any technical questions that may come.

You okay. Well, thank you, Dr. Ghaly, for that overview. And I think, as you said, this is another step in everything else that has transpired over the last 20 years as far as Affordable Care Act, expansion of medical cal, aim, and being able to pay for more services. So this is in concert with all of those questions or comments from my colleagues at this time. Go ahead, Senator Roth. And then we'll go to Rubio and Menjivar. Senator, Rubio up first.

I'm sorry, I thought she was first. Trying to be collaborative here. First of all, I just want to say thank you so much. I know this is a lot of hard work behind the scenes, late hours in the just at night. I mean, so I want to just thank our Chair Eggman and all your team as well as the Governor, for trying to do this important work, which I know is one of the most pressing, at least my personal opinion here in California.

And so I know we have had a lot of concerns about youth programs and we've heard a lot of the concerns. And clearly I have to at least tend to speak for my colleagues, that I'll speak for myself as an educator, being in the school system, knowing how much need there is in that area of trying to support our youth with mental health services. I know that you've done a great job in trying to strike that balance.

We want to take care of homelessness, but also making sure that our youth doesn't fall through the cracks. I just want to say thank you for that in particular. And I might have missed it. Just expand a little further since I have you here. You discussed smaller counties having the flexibility to invest earlier. Can you just elaborate on that concept, please?

Sure. So a few things first. In the original proposal, before these amendments, we really wanted to limit the amount of capital investment that the housing intervention resources could go to in order that we immediately activate those dollars to find available housing units and not necessarily wait because we have behavioral health infrastructure programs. CC other investments in some of the brick and mortar facility builds so that we could use those dollars immediately to house people.

Recognizing that not every county has the same opportunity, that creating additional access to capital funding in those housing interventions for smaller counties earlier in the process will allow us to make sure that county plans could create some of the infrastructure that they might need to achieve some of the housing.

Additionally, some of the administrative needs, with the increased focus on reporting and accountability, allowing some of our smaller counties to have additional funding to Fund those administrative needs so that they could meet some of the hopes and expectations in the reporting moving forward. So those are two main areas. Michelle, is there anything else? Those are the two key ones.

Thank you. And lastly, I guess I wanted to say because the amount of calls that we received and concerns I also want to say to everyone listening that's advocating for those youth programs that we were discussing is that this is just one program. But my colleagues and I continue to be committed to finding resources and funding in other ways. So this is just one piece of the puzzle, but we will continue to push. And so, once again, just thank you for your work.

Could you talk a little bit more about the services for kids and how we have adapted that?

Yeah, so let me dig in a little bit more. And one of the key initiatives that frankly embarrassed a little that I overlooked to mention as part of this broad tapestry is the Children Youth Behavioral Health Initiative. You all, in concert with the Governor, two years ago, put in place a $4.7 billion investment in children youth behavioral health. Some really transformative things that becoming envious across other states when we have the privilege of sharing what we're doing here.

Part of that is also it needs a new name. We call it the Fee schedule. I call it the schedule of opportunity for schools to be able to deliver directly certain behavioral health services to their students. That allow us to not just pay for it through Medicaid resources. But as part of our agreement, commercial health plans will also be supporting those.

So over the next handful of years, starting with some phase one counties in 2024, we will be using this fee schedule to allow us to provide some of those services that, as you mentioned, a focus on schools. We should see that increase with respect to the Behavioral Health Services Act reforms and amendments we are MHSA originally had through its regulation protections for a certain amount of the prevention and early intervention funding going to young people.

With the amendments today and the early intervention and the prevention bucket that are now in print, we actually commit to an even greater total dollar amount than in that original regulation to support prevention and early intervention services for young people under the age of 26.

Senator Menjivar, Senator Roth, and then Senator Nguyen.

Thank you, ma'am. Chair, Secretary, Director. Thank you so much. Some of the exciting things that I looked at, it know, clarifying the usage of these funds for SUD, especially for our youth. I took a tour of Tarzana Treatment Center in LA County, which is the leader in Sud treatment and so forth. And I found out in LA County, one of the largest counties, there's only one facility for youth residential treatment, one for LA County.

That's in noncaster, an area that oftentimes youth don't want to go to. Right? So I'm hoping that clarifying this, we get more facilities like that and so forth. I'm happy about the accountability for counties, the oversight on the counties and so forth. I'm happy with these amendments. And just to clarify, because one of the concerns was that we were missing the TAY population. So all the programs, Secretary, they mentioned is everybody 26 and under when we talk about children and youth. Correct? Correct.

Perfect. Okay, so into the questions you mentioned CYBHI a couple of times. One time funding, however, that funding will end and it's being looked at if correct me if I'm misunderstanding this, as something to supplement this. I'm wondering where we're going to continue. If there's conversation. There's an idea on how to continue Fund that if this is being looked at as something to, again, supplement.

So there are definite parts of the Children Youth Behavioral Health Initiative that are one time startup in nature, investments in the platform, some of the workforce investments. But there are aspects of it that are ongoing. The fee schedule, this opportunity schedule, as I like to think about it, that's ongoing, that's not going away. We've committed to funding those services. Some of the other things like diatic services, that is now a benefit in Medicaid, that's not going away either.

So some of the core features of the Children Youth Behavioral Health Initiative are not one time they will be continuing. That said, between Children Youth Behavioral Health Initiative, some of the important aspects of the BH Connect Initiative, which we're excited to have Director Boss's team continue to share with the Legislature and others what we have in plan there with our federal partners. I see these as really not just on ramps, but continued roads to Fund some of these critical services into the future.

So I think it's really important. I often hear while that's one time in nature, there are some startup and build up costs that are one time, of course, but there are aspects of it that will continue on into the future.

If I may also just add in terms of the early intervention allotment of dollars. We have new language here really requiring the Department to come up with kind of a biannual list in consultation with the OAC and other partners of evidence based programs that meet kind of the early intervention objectives. And we have a reference to those that are established through the Children and Youth Behavioral Health initiatives.

So recognizing some of those initiative grant dollars are intended to scale up some of these programs statewide where we know they're working somewhere, but really to scale these up. And they're providing MediCal dollars to support some of the Reimbursable services and then BHSA as kind of the grout that is needed for services that are not MediCal reimbursable. So really thinking about how do we scale up and kind of put this as a list of what counties are required to provide.

Thank you, Madam Chair I have two more if that's okay. My second one is on technical assistance, you know, CalAIM, phenomenal on paper, but I think every provider will tell you it's hell for them. They can't Bill, so even though the resources are there, they're unable to bring those to individuals. I'm looking at this as similar to CalAIM. What have we learned from that? What technical assistance are we going to provide accounting to ensure that isn't the same as CalAIM.

So I will say we have learned a lot with CalAIM and really just going throughout the states we have and are making policy changes to try to simplify and standardize some of the kind of the program requirements, eligibility requirements, billing requirements. But these changes are rolling out now and kind of will be coming through the end of this year. But as part of this we do have just kind of that technical assistance is needed.

The OAC will be part of those conversations to really understand what does it take to implement, what do our providers need, what guidance. A lot of this too is going to be about that blending and braiding and the opportunities to leverage each other's programs and dollars and how do we help counties and providers and CBOs think through how to leverage and really take advantage of really pulling this together.

The other thing I'll add is I think the conversations around Behavioral Health Services Act reform the Calian conversations, there are other conversations which really highlight that California's plan and dream to leverage community based providers is incomplete without a clear understanding of how we're going to do that. Technical assistance and support some of these groups to actually be able to access those funds through Medicaid. And frankly speaking, some of the groups top, we often talk about work to the top of your license.

Doing all of the administrative activities in Medicaid are probably not the best use of some folks time. So we are on the hunt for strategies to figure out how to make that easier on the whole. And I think that's not just relevant to this, not just relevant to CalAIM.

I think that's an across the board aspect of our success moving forward to really benefit from this idea of, "Hey, we're moving outside of hospitals and clinics into community based services provided by people with lived experience, people who come to work and live in the communities that they work in, so that we can really maximize this opportunity." So I just want to take that moment to say this is a broad important issue that goes beyond just bits and pieces of technical assistance at the county level. We need to figure out how to do this more broad. And I know Director Baass' team is thinking hard about that.

Quick follow up. I'm sorry, I promise. Just quick follow up. Small follow up. Director, because you mentioned about leveraging the community partnerships and focusing on the youth and children, the importance, but I don't see schools involvement in that collaboration. Maybe I missed that.

Schools are definitely part of it. So as part of that county integrated plan that we're asking is really replacing the three year MHSA plan. It includes schools both early education, higher education, K-Twelve. The list of stakeholders and partners involved in that process has expanded tremendously. Area Agencies on Aging.

My actual third one, could you break down the 3% that is being pulled away from counties for workforce. And what would that look like?

Sure. So first, one of the first things that a portion of that 3% is going to be used for is to support an aspect of the BH connect proposal wherein roughly $36 million a year for five years will be taken from that 3% and used to leverage a total of almost $2.4 billion at the federal level to invest in workforce initiatives, in part to build up all of the programs to allow us to, frankly, staff and support a lot of the Medicaid services that are critical to the BH connect piece.

So a portion of that 3% in the first five years is going to be committed to leveraging federal dollars. We hope, frankly expect that we may be able to do that a second time to allow us to have this leverage opportunity.

Beyond five years, up to ten other funds will be used in collaboration with our labor partners, our county partners, our other provider partners, to make sure that we are supporting initiatives, whether it's upskilling existing workforce or inviting others through investments in bread and butter, social work programs or other types of programs. Or and I would argue part of California's challenge is to find the new types of classifications and behavioral health that are going to help us in California in the future.

So big part of it is really leveraging Medicaid and the workforce initiative through BH Connect, and then beyond that, it's working with local partners to design workforce programs, not just one time spend. This will be ongoing money to be able to support building up the workforce locally and with a priority of understanding what the county Behavioral Health Department needs are so that we make sure to build.

Whether it's Los Angeles or a smaller county, we're helping support them in building up and recruiting the workforce they need to deliver these programs.

Thank you.

Thank you. Sounds like same day billing could fit right in there just while we're streamlining. Senator Roth.

Thank you two for working this very, very important issue. I have a confession to make at the outset, and that is I haven't begun to master the original Bill, and I really haven't even had a chance to look at the 200 and something page version as amended, that apparently came out. And we've been asked to limit our questions, so that's good. So I can't ask specific ones because I would really reveal how little I know about this. So I'll ask a general one.

What I was able to read in the material that was available talks a lot about allocation of money into buckets and percentages of money into buckets and categories of money and what it is. And it sort of reminds me of education finance, where we had categoricals and we worked through local control funding and how we were going to deal with that with school districts.

And we've largely moved away from categoricals for a good reason, because school districts and communities differ around the state, given the variation and differences between the many counties that we have in terms of housing and treatment programs and populations and population needs. Instead of trying to do this in a bucket by bucket approach by percentages, wouldn't it be better to set goals and objectives and establish desired outcomes, whether they're general or specific?

Whether we do it as a state or we let the counties do it and submit it for approval and adjustment by us, wouldn't it be better to do that and then let the counties figure it out, at least with some guardrails? As opposed to the current model, which is bucket centric, percentage centric, we're going to allow them to adjust by 7%. What if one county's housing needs are minimal for whatever the reason in comparison to another county's needs in another part of the state?

What if one county's population needs less treatment or more treatment or early intervention than another county? And yet we have created in something that this goes to the ballot, does it in something that's gone to the ballot, a fixed system that is almost impossible to adjust just like the original MHSA, and then we have to go back through this process again and go back to the ballot. Does that question make sense?

It makes lots of sense, and I'll respond a few different ways. First, in today's system, we have fairly rigid buckets without some of the other parts that you're accurately calling for outcomes, metrics ability to actually collect data around those present. It transparently, not just at the state or department level to the Legislature, but to all Californians to understand what this important voter ratified, two decade old bucket of resources is actually helping us achieve.

So I'll start by saying absolutely an anchor of this reform is establishing those metrics both at the state level. So statewide metrics that could be universally applied and focused on, but allowing through the planning process that Director Baass mentioned, fairly robust to create some local metrics that matter, are driven by their own needs, their own data, their own sort of where do they want to move, what are the partners speaking around, what are the families, the peers, other groups saying?

So establishing that, I think, is critical to this piece on the funding side, recognizing that the opportunity to make sure that the various broad elements are invested in adequately with some flexibility in the buckets to be able to move across.

We believe, with the North Star being those statewide and county led metrics, that these buckets with that flexibility are going to allow counties to really achieve what we expect to see and do it in a way that we will be able to report not just to you, but to populations broadly about the impact. So sure, there may be other approaches that one could imagine, but we believe that this approach, with the flexibility, anchored with this accountability structure that's frankly new to have it statewide.

Not that there hasn't been elements county by county or on specific issues historically for a period of time, but to have this now be kind of the leading edge of this entire reform I think is really important.

Well, thank you for that response. Thank you, Madam Chair. Appreciate it.

Senator Nguyen, did you have something? I did.

Thank you, Madam Chair. Mr. Secretary, a couple of things. One is I know the Mental Health Services Oversight of Accountability Commission. They serve a very important role and very independent. How does the plan preserve that independence and that commission and its role?

Yeah, I think important. Good question. And in the original proposal that independence was preserved. I think some of the amendments, although subtle in the updated language, really put the onus on the Department and the oversight commission, the Department of Healthcare Services, the oversight commission and in some places CDPH to work together on. Coming up with what the statewide metrics are, determining what technical assistance looks like and not having it fall just in one place or the other.

So not only do we think that independence is preserved, but it also, through this language and update, creates opportunities to frankly collaborate in ways that the Oversight commission and the administration's departments haven't historically done. My hope is that we're sort of ushering in a new approach with these partners to make sure that we're putting our best foot forward. There's staff in both places and that staff should be sort of unleashed in a collaborative way.

So we believe the independence is maintained, but we've taken opportunities to make sure there's opportunities where appropriate and where prescribed to work together in a stronger way.

And if I may just add, some of those opportunities are areas where they have expertise, where they've had a lot of work in the past few years. Full service partnerships, for example, as we develop the level of care, the standards of care for full service partnerships, working with OAC on that definition. In addition, innovation.

We want innovation sprinkled throughout all of those buckets and so really looking to them to provide guidelines, ideas, kind of a statewide list of what are some innovative programs that belong in each of those buckets for our counties.

And I appreciate that. I want the collaboration, but I also again want to make sure that they can give us their opinion without having to be felt like they're being influenced or expected to go a certain way.

Yeah, we both expect that. Heard that loud and clear and really tried, and I think achieved, language that preserves that independence while allowing us to really work together in a way that historically maybe has been under recognized.

One more question actually, on the allocation the proposed funding categories you have there, where it's the housing intervention, one of it says 50% must be an individual who are chronically homelessness. What are we doing different than Section Eight or the other county fundings already for, because there's county funding today that are specific for individuals who are chronically homeless and that needs to get in housing immediately. Are we doing the same thing or are we doing something different, and are we targeting a different base?

Yeah, first off, the individuals who will be eligible for housing interventions are people with severe, persistent behavioral health conditions first and foremost. That isn't always the priority in other programs. So that is sort of the first criteria for entrance. And then having that focus on those who have experienced chronic homelessness is to say that often individuals who are in encampments, suffering some of the hardest parts of severe behavioral health challenges are easy to pass by, easy to move on to somebody else.

And this is really requiring counties and their partners to focus on those individuals not only first and foremost, but in addition to other populations as well. This is our way of making sure that people don't fall through the cracks who typically do.

So we're going to actually have specific guidelines for this funding then?

Yes.

I just want to make sure, because every time we send funding down, we love the counties. We're not as big as LA County, but we're not a small county. I have most of my districts in Orange County, so we're kind of in. So sometimes we get fundings that it's just so overly broad. And I want the funding to go specifically to what we believe is needed.

Yeah, I think that within the housing intervention bucket, we believe that that ability to guide it to those with severe behavioral health conditions who need housing exists while also making sure we focus on those who, as you know very well in Orange County, are experiencing street based or chronic homelessness.

Thank you.

Yeah, thank you.

And again, these aren't people we are making up. These are people who already live in every county right. And who theoretically are under the umbrella of MHSA, leaving it just for counties to do. And again, not counties aren't bad, but those are very hard populations to treat. And unless you really mandate it, it's harder. Senator Wiener.

Thank you. Madam Chair. Mr. Secretary. Thank you. And I want to thank you and the chair and the Governor for this work, and I support what you're doing. I also do want to just thank you for working with the youth advocates and making clear that this funding still needs to prioritize the needs of youth. We know that that's when mental health challenges tend to arise, and it's just demoralizing how few resources there are for the mental health needs of young people.

But I know this is hard because in 2018, I did a Bill, SB 1004, for the Early Prevention, early Intervention piece of MHSA, working with Mayor Steinberg to prioritize some of those funds for the needs of youth and other stakeholders quickly came out and pushed back against. So I got to look under the hood and see the politics of MHSA. And so I want to commend you for doing that work. So thank you.

Thank you.

And before we move to the next panel, can one of you and maybe Toby will do this when he comes up too? Because I think one of the most exciting, necessary things we're doing around early intervention is being able to focus on early psychosis. Right.

We know that if you intervene there and again, that's young people between the ages of 15 and 20 for the most part, and I think the US is kind of behind on really prioritizing that and standardizing that and making it just so any county can follow a protocol. Can you talk about that as one example before we move on of how we might really be able to scale that up to a larger place, early psychosis?

Sure. Just quickly, and I'll appreciate Toby's comments on this when he has a chance to testify as well. And Director Baass and I have had lots of conversations, learned quite a bit, especially even thinking about the Children's Youth Behavioral Health Initiative, about what some of the counties across California are trying to do across county lines as well with health systems to be able to prioritize early intervention for early psychosis.

As Director Baass mentioned, one of the features of the early intervention funding is, yes, a focus on young people, but also a biannual list of evidence based programs that will be on a menu, if you will, for counties to choose from. But on that menu there will be some required aspects. And having a requirement to focus on early psychosis based on the evidence and the demonstration that it makes a difference that we know that so many of the psychotic disorders that affect adults start earlier.

Having the ability to make sure that first episode psychosis is met with the kind of intense resources and communication with families, with young people to make sure that they're captured in evidence based programs is one of the priorities.

And will be a feature across California supported not just through Behavioral Health Services Act funding, but additionally through children, youth, behavioral health funding and hopeful innovations that we discover and build here first, not import from abroad, because we have that ability here in California to push the needle as well. So I think that's an exciting feature. Thanks for letting us highlight it.

Absolutely. And I just wanted just to compliment Dr. Ghaly. He has been bullish on being able to for youth and families and schools to be able to pull down as much private dollars as possible, that we don't need to use public dollars for everything. There's a lot of ways to be able to access that, especially in schools. So I appreciate that. Mayor Steinberg has reached out to me to ask me if he can go next just for a brief time. I don't know.

Secretary and Director, stay by close, because everybody who talks is probably going to you might want to respond. So Mayor Steinberg come up, and then Toby and my friend Will with the beautiful voice that can start making your way up as well, because then you'll be on next. All right, Mayor Steinberg is going to head to the Bay Area, so he's just going to be brief and be here for a couple of minutes just to talk about he's the founder.

Thank you, Madam Chair. Thank you for your courtesy. And the other Members of the panel. I do have to have a family matter. I have to get to the Bay Area, so I really appreciate it. Good to be with you. Members of the committee, old colleagues. Thank you for having me.

I thought my best value today would be to provide a little bit of the history of the Mental Health Services Act and how it relates to today's proposal, as amended, which, by the way, I wholeheartedly support. And I commend you. I commend the Governor, secretary, Galley, Director, boss, everyone who has worked very hard to bring this forward. This proposal was great prior to the amendments. It's even better now. The history is important. How did this all get started?

When I was a young Assembly Member elected in 1998, I was given some sage advice. Work on something in your six years, because it was just going to be six. That is really important to the state that no one else is working on. You'll be able to have your own North Star and you'll be able to make a contribution. And I met a gentleman by the name of Rusty Felix, the late, great Rusty Felix, who was the head of the Community Council mental health agencies.

And together, in 1998, we wrote AB 34, and AB 34, which became AB 2034 over the course of two years, we were able, even in tough economic times, to convince the Governor Davis and the Legislature to put $55 million into what we called integrated services for the homeless, mentally ill, whatever it takes, assertive outreach, case management, wraparound services, shelter and housing for people.

And over the course of those first years, we showed dramatic improvements in reductions in rates of hospitalization, rates of days of homelessness, the number of arrests, increased housing placements, and even the beginning of increased employment. In about 2003, we looked at each other and said, are we satisfied with $55 million a year?

Because the original premise was to try to get the state to uphold the promise made by Governor Reagan and the Legislature back in the 1960s when they shut the state hospitals to fund a decent system of community mental health care. And we thought maybe, Audaciously, that if we went to the ballot, that we could uphold that promise. And so we did. And we put together Proposition 63 and we're the first to choose the millionaires tax and under the radar campaign. Many other things going on.

We passed it with 53% of the vote and over 20 years the act is, I think, maybe a little bit of author's bias here has been a great success. I don't think the counties have misspent the money, just the opposite. I think they've done a good job with the money. But if we're honest about it, if we're honest about the world has changed over 20 years. No one was working on mental health then.

Now mental health is the issue of our time, if we're honest about it. Up until Governor Newsom took office and appointed Secretary Ghaly and made these issues a signature priority, the flaw in the Mental Health Services Act has not been the county's fault. It's been that the state of California has never set statewide priorities. And what they want is massive amount of money because it's now $4 billion plus to go towards. And so over 20 years, the counties have done a good job with the money.

But if we're also honest, we will say that the full service partnerships, which are the wraparound services, the coin of the realm, the AB 34 model, have not been focused on the chronically homeless. They just have not. And for many reasons. One, it's a really hard problem and hard population and maybe it's a little bit more expensive. And I don't say the counties have creamed or the program fighters have creamed.

They're helping people with serious illnesses, but they are not focused on the people living in the tent. Encampments. And so Governor Newsom comes along in his Administration and Senator Egman with you're now, the legislature's leader on these sets of issues, thank you are saying how do we fulfill that promise from now, what, 60 years ago? 60 years ago?

Well, it's not just MHSA, because frankly, one of the burdens of MHSA is it's had to bear all of the public mental health responsibilities because there hasn't been much else. But now you have Calam, now you have the youth initiative, now you have a real commitment. And so there is an opportunity now to actually build the system and to go back to the MHSA's original intent, which was not to focus exclusively on chronic homelessness. And that's not the way we wrote it.

Rusty and I said 20% for prevention, early intervention, 5% for innovation. But to focus it primarily, at least the service pot on the people who are the sickest of the sick. And that's what this modernization proposal would do. It is consistent with the original intent and as amended now, it gives the counties proper flexibility. Secretary Galley is right. Adding the 51% for youth was a very good move. There's actually more money for early intervention than there was in the original act, except not to accept.

And the state is simply saying, we want you counties to focus on the strategies of your choice, but they need to be evidence based. And I'm so glad, Senator Eggman, that you raised the early psychosis identification intervention strategy because the truth of the matter is that is evidence based. It's working.

And we have 30 or so programs around the state which are not nearly to scale and with this kind of push we could get that to scale and think how many teenagers we can get into wraparound services before they have that first psychotic break or just after. And so I'm really enthusiastic about this because for me this actually fulfills this overall measure, fulfills the original intent that motivated me 20 years ago to want to do this.

Homelessness was a problem then, now it's a worse problem and a worse crisis now. But we must focus these resources, more of them on helping people and helping our state and our communities change this cycle that is tearing us apart and is accommodating, whether we admit it or not, unnecessary suffering around the board. So thank you for the moment and the time.

I'm joined, I know by my Karen Larson and the Steinberg Institute team who've also been really instrumental in working with the Administration, with you not just this year but over the past couple years to lead us to this historic moment.

They've been great partners, great partners. Thank you. Any questions for the mayor? Okay. We do appreciate your leadership so much and I think when we talk about this early psychosis, that young man in Davis that just murdered three people, right? If you look at his case study, that is an early episode. He was at 20 years old, just started show signs last year of high school, first year of college and now he's murdered three people.

So many tragedies could be avoided and so much suffering could be avoided and demonizing of people, let's help them. But I have hope and I know you do too. Thank you.

Thank you very much. Thank you mayor. Now we're going to invite up Toby Ewing from the oversight and accountability and Will Owens with the and Ryan Miller also coming from the LAO. Welcome, gentlemen. Will, you're listed first. Do you want to start out?

I love his voice, so I want him to sing it for us. And he does sing. I asked him. He's in a band? Choir.

Unfortunately, I haven't prepared anything this afternoon, but more advanced notice. I'm sure we could put something together.

We'll all sing with you, brother.

Well, thank you very much for having us chair and the committee. My name is Will Owens with the Legislative Analyst Office. I'm here with my colleague Ryan Miller and today we'll be talking a little bit about the posts we've done on the governor's proposal as well as some of the conclusions we've drawn from them. I will note that our posts and our analysis are on the pre amendment version of this legislation. To that extent, we are still evaluating the impacts of this, but that is the focus of our analysis. If you look in your handout and.

Mr. Owens, would you say that as far as you've been able to look at the amendments, they address many of the issues that you brought up and you were also in a hearing with us?

Yes, I would say that it appears that many of the amendments may have some impacts on the various issues for consideration that we raised before the Legislature to the extent that we know what those impacts are and the impact of those is unclear at this time, and we're still working through those.

Thank you.

So if you look in your handout, we have four posts that we discussed and analyses that we'll talk about today. The first being kind of the change in categories and the impact of those on county spending. The second being the impact of the proposal on funding for children and youth. The third would be the general revenue volatility of the MHSA and the proposals to reduce the allowable county reserves and the impact that may have.

And finally, we want to talk about the proposed changes to the OAC's role and authorities in the proposal. On page two of your handout, we have the key takeaways from our posts. Just as a reference, we'll kind of talk through these, and I'll try to emphasize the points from our analysis that we think are particularly pertinent, especially in light of the amendments. So the first post that we'll talk about is the impact of the categories.

Generally, what we find with the governor's proposal is that there is a shift in funding focus towards full service partnerships and housing interventions. So some of the impacts of that being that there are a number of current services that are funded by the MHSA that could see redirection or reduction in MHSA funding availability, those primarily being outpatient services, crisis stabilization, wellness. Centers outreach that would be funded through that BHSS bucket, which we estimate is currently, I'd say maybe over prescribed in terms of current services.

So generally we find that there would be a redirection. Some of the issues that we raised for legislative consideration is that we find the administration's analysis of the impact on current services to be incomplete, in that at this time it is unclear what services and what potential impacts this kind of refocusing on FSP and housing could cause. We do know that available research suggests that both FSPs and housing interventions are effective ways to treat certain components of behavioral health.

But at the same time, with the redirection of funding, it's unclear what the net impact on behavioral health outcomes in the state would be. With that, want to touch briefly on the impact of the proposal on children and youth. As noted by the Secretary, there were recent amendments that included a funding requirement for children and youth. There is no current statutory requirement for children youth funding under MHSA. It's done via regulations.

And so with the amended proposal, we still find it's a little unclear how much children and youth funding would be available and what services would be kept. Even light of this new funding requirement, it's unclear to us and we haven't seen analysis by the Administration of the Specific Services that would be kept. With that, I'm going to turn it over to my colleague Ryan Miller to talk about the revenue volatility and reserves.

Hi, Ryan Miller LAO and to address your question, Madam Chair, we are still looking through the amendments on a number of the aspects of the changes, but upon our first review, it does not seem that the amendments impact the analysis that I'm about to cover. So the MHSA, as Mayor Steinberg mentioned, is funded by the so called millionaires tax, a 1% surcharge on income over $1 million, and the revenue is extremely volatile.

We have a figure on page nine of the handout in front of you that illustrates and compares the MHSA revenue to the state personal income tax and the state sales tax. And as you'll see in the figure, in many years, the year over year change in the MHSA revenue can be two or three times more than the personal income tax, which is what really is the source of the state's revenue volatility that many of you have probably heard about.

So this creates a pretty challenging situation for counties in terms of trying to manage their Fund and provide ongoing and consistent mental health services. So in this context, the Administration has proposed reducing the amount of eligible or sorry apologies, reducing the amount of allowable reserves from 33% in current law.

To put it on an apples to apples basis, it would be to about 20% for large counties and 25% for small counties. In order to review this proposal, we looked at historical MHSA revenue and tried to look at what allowable reserves would have been and compared those to revenue declines that could have happened, that had happened in the past, to get a sense of how the caps would perform in the future.

And in our view, we actually think that the caps should be higher than they are in current law. And so we would say that the governor's proposal would move the reserve caps, the county reserve caps, in the wrong direction. In addition, we think that this conversation presents an opportunity to sort of revisit the funding source. And so we've actually recommended that the Legislature change the funding source. We've offered some ideas that could involve just sort of depositing the money into different accounts.

They wouldn't necessarily involve changing taxes than any taxpayer pays, but there are ideas that could substantially reduce county revenue volatility while really having a small impact on the state. And we would also note that our ideas are not the only ones out there that the counties, we understand, are also talking about potentially some kind of like, rolling average or other. So there are other ideas, but ultimately we think that it's really important that the Legislature try to match the level of reserves to the revenue volatility.

And so if there isn't any kind of change to address that, then we think that the governor's proposal might put some excessive fiscal risk onto the counties. In addition, we also just think that the counties could use some additional flexibility when it comes to managing their reserves. For example, we're not really sure that it makes sense that the state would impose both a cumulative cap, but then also a cap on the annual amount that could be deposited.

So happy to take questions after my colleague Will has finished.

So the final post that we want to talk about is the impact of the governor's proposal on the OAC's role and authorities. So generally, we find that the OAC is a valuable partner to the Legislature in terms of its independent role in overseeing the MHSA. However, under the proposal, the governor's proposal, I should say, reduces the authority and direct program oversight that the OAC has over many of the MHSA programs, in particular with the removal of the prevention and early intervention bucket.

As it stands, the OAC role in priority setting, rulemaking and direct oversight of those programs has been removed. Now, with the recent amendments, there are some changes, but generally we find that the OAC to be able to act fully and independently and to perform its role absent a compelling justification by the Administration. We would recommend that the OAC's role in terms of direct program oversight, rulemaking, authority as well as priority setting, be maintained, which it is currently not under the proposal.

With that, happy to take questions on any of the points we made or anything else.

I think we'll hear from Mr. Ewing first and then we'll take questions.

Thank you, Madam Chair and Members. And I appreciate that the LAO referred to us as a valuable partner. It's nice, especially in that wonderful voice, as you pointed out. Toby Ewing, on behalf of the Mental Health Services Oversight and Accountability Commission, really appreciate the chance to join you and many of my colleagues and to engage on this very significant discussion about what's happening in California around mental health needs and outcomes and how we can do better.

As many of you know, and as Mayor Steinberg pointed out, the Mental Health Services Act really is a landmark body of policy that was really designed to support transformational change. And it had a couple of components. It has a couple of components. It really emphasizes the need to provide tailored based care to folks who are struggling with the greatest needs. We can talk about whether or not it's doing that.

But the design of the policy really was to really move us away from decades of rationing care with very restrictive sets of rules around what we could do and to begin to shift our strategies to be more responsive to what's happening in local communities and in individual lives and families. Its language around early intervention I appreciate the mention around early psychosis.

It required prevention, and it articulates a very broad definition of prevention that really gets at what's happening in our communities in terms of threats to well being, there's long been this tension over whether limited funding should focus on those with the greatest needs versus doing the upstream kind of work to prevent those numbers from happening. We find that that tension isn't as real as it's often made out to be, because if we think about mental health resources as MHSA Dollars or Realignment Dollars, that tension arises.

If we think about mental health resources much more broadly and how we can deploy your comment about schools, the workplace, parks, employment opportunities. Mental health and well being is really about having a place to live that we're comfortable with, people around us that care for us, and having hope, which is often in the form of a job or education opportunities, or time to spend people to spend time with. The Governor's proposal is very timely, and it highlights the areas where we've really failed to do enough.

And I just want to be very clear on that. I don't think that's up for debate. Housing, addiction prevention, early psychosis and other forms of intervention, and how we thoroughly leverage opportunities to tailor care again through full service partnerships. Because of the emphasis on folks with the highest level of need, we are still working through the amendments, but they do address many of the concerns that the Commission has raised. We do not have a formal position. We're talking with the Commission as soon as next week.

But on behalf of the Commission and personally, I want to thank Secretary Ghaly for the time that he and his team have spent with me and with the Commission to really work through and understand our concerns and our conversations are continuing. There's often this concern about the Commission and our independence. We are an independent body today. We're also a core partner with the Administration.

We have done some phenomenal things with the Department of Aging, with the governor's office of planning and research as recently as last week around some of the precision medicine grants, around depression, with the Department of managed healthcare, with CYBHI, and of course, with the Department of Healthcare Services, who really is our closest partner when it comes to transformational change. That doesn't mean we agree on everything. I use the reference of we're like siblings who often share a bathroom.

We get along in many, many ways, but at times there is conflict and so appreciate the comments about our ability to speak independently. That does not get in the way of our ability to actually work very closely row in the same direction with the Administration. We do have some concerns that we have not yet been able to clarify in terms of the amendments. They may be addressed in the amendments, we're not sure.

But first, strongly urge the state to not tie its own hands by having to go back to the voters to make amendments. The level of change that is being pursued, the complexity of the mental health system, the opportunities we have to leverage private sector dollars, private sector capacity research, all of the accountability work.

This is a big initiative and the more in which the Legislature and the Administration can retain the authority to make adjustments over time will serve the state's needs as we learn, as needs evolve, as our experiences improve, as these changes are implemented. Second, flexibility is always preferred where feasible, and we're concerned that the fiscal categories, particularly in state operations, may not have sufficient flexibility.

So one of our questions is will that 10% be subject to budget appropriations and will there be flexibility as we think about the kind of urgent issues that have arisen over time just in the last few years? We don't know what the next pandemic will be, the spike in suicides and so forth. Just our read of the language is does it bypass the budget process, does it go through the budget process? And is their flexibility consistent with the language in the ballot measure?

The state and counties have really been able to leverage the existing innovation component of the MHSA to support fundamental improvements in service delivery. Solano county saw 300% increase in access to care for the hardest to reach communities because trust levels were Low. 40 counties are learning from that. Solano Innovation Plan the early psychosis progress that we have made to date started with counties using innovation funds to get there.

Criminal justice diversion activities have been supported with innovation and we're scaling those as fast as we can across the state. Housing, mobile crisis, integrated electronic health records across counties, stigma reduction, youth empowerment, school mental health. The Administration is clearly committed to innovation above and beyond where we are today. We're not clear what the mechanism is to ensure that that actually happens. And so we're still talking with them about how we can ensure that innovation happens in the public sector from our purview.

Innovation happens every day in the mental health space. It's often funded by the private sector. And unfortunately, private sector innovations don't always touch public sector needs, right? We have been working under the current scenario to try to build stronger bridges between private sector and public sector innovation, to really bring the full force and influence of all of California to bear on the challenges in front of us. And so we're continuing to talk with the Administration about how we can retain that opportunity.

We're very appreciative of the work that's been done on school mental health. With the passage of the Mental Health Student Services Act and CYBHI and tremendous step forward on the integrated planning bringing in Area Agencies on Aging and schools and other partners who touch mental health and well being, we would encourage some additional attention on ensuring that leadership at the state level on school mental health is sustained beyond CYBHI.

Probably not the time to do that in this momentous reform, but just put a placeholder there is that we think school mental health needs to continue to get the attention and investments. We want to make sure that after this reform moves forward that we don't forget or miss the opportunity to really continue leveraging schools. Our analysis we called out the need for fiscal flexibility. We appreciate the amendments on that issue.

We are a little unclear if a 7% shift in the housing category, for example, means counties would be able to shift from 23% to 37%, or if it's 7% of 30, which is 2%, and that would be a 28% to a 32% shift. So the language, again, I'm not sure if we just aren't reading it right, but some clarification on that a simple 2% shift in a 30% bucket may not be sufficient to address change needs over time or across diverse California counties.

We'll spend more time reviewing that, but we'd hope that some of the smarter folks that you have on your team might be able to help us understand that better. We really appreciate the focus and restatement to this commitment on accountability. The state and the counties have not yet fulfilled that commitment to the public. We have worked hard on that, but we clearly are not there. And so we look forward to working with the Administration to develop an implementation plan to get there.

I think that's sort of the gist of my comments is that the scale of these statutory changes will require a comparable level of effort on an implementation plan and that's going to take time. That should not be done through the ballot measure that needs to be recognized in statute. It should primarily be done through the budget process and through conversations with departments over time.

Thus my comments about securing flexibility on the state administrative side, particularly if the Legislature can retain that, so that we can make sure that the real work, which is following through on the statutory changes over time, can be done in ways that are responsive for those concerns we know of today, but most importantly, for the concerns we had not yet anticipated. Thank you for the chance to join you. Happy to answer any questions.

Yeah, thank you so much. I love that and I think that's incredibly important that we'll be able to and I think just use the example of how things have changed in 20 years to maybe be able to make some statements before it goes to voters about some room for flexibility as things change that are in the spirit of what we're doing. I don't know. I think it can be worked on questions from Members. Senator Limon.

Thank you. And I just appreciate just kind of following up on that comment and on flexibility too. I think know one of the important things as well is thinking. I love the idea of the Legislature maintaining control of flexibility. Just to be clear. That's what I like about that. But the other piece is flexibility. We have 58 different counties.

And I think that this is what some of my colleagues have alluded to, but I think a lot of what it takes to create facilities and sustain facilities with beds and what that means in areas across our state, whether they're rural, urban, inland, coastal, central, in terms of real estate markets and in terms of actually finding facilities that can be sustained rents that can be paid by facilities. And that's another big piece that I think is important.

And your comments just triggered my thinking on that because we will need also flexibility to understand how we deliver in 58 different counties. It's not going to look the same the way we would deliver in a potentially rural area of the state is going to look different than in an urban area. There are real impacts, also geographical and local, county, regional impacts that will have some kind of, provide some type of direction on how and when and the type of delivery that can be made.

So I hope that we keep that in mind and that we are clear with the voters that we all want the same outcomes, but perhaps how we get to those outcomes in different parts, and this is not to favor anyone over the other as much as to understand that the idea of creating specifically around facilities, right, creating beds is not an idea that can be implemented in the exact same way everywhere.

And it might look slightly different and take different level of human, fiscal, material resources to be able to achieve.

Thank you, Senator. Yeah, and thank you to all of you. Dr. Ghaly and I already been mind melding each other on the flexibility part and also on the volatility issue when we first talked about that. I found it very interesting and continue to do to be able to use the big massive state General Fund as a backdrop to be able to steady out the amount counties can expect to come down every year. I just think that makes total sense. So we really thank you. Thank you. Okay, I appreciate your service and your partnership. You've been integral parts in all of this.

Okay, so now we're moving on to our next panel of stakeholders. And again, as the last panel said, so again, right, we had what we're doing then all these implementation issues, right? It's all the weeds that devils in these details. And then we want to be able to hear from stakeholders who are actually going to be on the ground as these things come down. So we already heard from Mayor Steinberg.

Now we're also going to invite up SCIU with Matt Legé, Kim Lewis, and Dr. Leandra Clark Harvey. What? Lions, tigers, and bear. We're doing these four and then we'll do the next group. But thank you for the prompt. Okay, Matt, you're listed first. You want to go first?

Certainly. I thank you, chair and Members, for letting me speak today. It is my pleasure to be here on behalf of SEIU California to express our support for the proposal to modernize the Mental Health Services Act. SEIU represents a wide range of behavioral health and service professionals across county and community based organizations, from case worker, treatment counselors, peers, navigators, and of course, social workers to everything else in between.

As well, as many of you may know, SEIU played a critical role in the passage of Proposition 63. We work both here in the Legislature and at the ballot box to see it come into fruition. Because of our mental health, public mental health services were not meeting the growing needs of California, and frankly, the MHSA has not kept up with the type of care that our communities need today as well.

And now we're facing greater challenges than we did in 2004 when the MHSA was passed by voters. Our challenges are multifaceted, including a growing opioid epidemic, a housing crisis that has led to many homelessness, growing population that is leading the nation. Unfortunately, in addition to growing demand for behavioral health services, on top of all of this, and partly that demand is not being met because we have a shrinking behavioral health workforce to try to serve these needs and meet the demand for services.

That workforce is facing impending retirements and the need to continue to diversify to reflect the populations that we serve. For example, in San Diego alone, which has a reported 8000 of 100 behavioral health workers by 2027, is estimated that they're going to need 18,000 behavioral health workers, which is more than a 200% increase for that county. And that's just one county alone. We're here sounding the alarm around the workforce crisis.

It's, of course, across the healthcare workforce, but I would say also acutely felt on the behavioral health. You know, this is not just for the healthcare workers who really need know, have fair wages and the resources to be able to deliver care. But also here on behalf of the SEIU Members, both the mothers, the fathers who day in and day out are grappling with the painful challenges around dealing with the potential of losing a child due to substance abuse.

Many, unfortunately some of our workers are also living in the cars and dealing with the housing crisis and dealing with that mental health crisis that happens from being housing or being housing insecure because they can no longer continue to live in their car to try to not be able to get the basic supports they need. So with that, just wanted to provide that context. But first and foremost, SEIU supports this because we believe it's a holistic, compassionate approach to care with a focus on equity.

And this proposal we think is a good start. We must ensure consumers with severe and serious mental health illnesses and substance use disorders or those who are at risk have the ability to access quality care they need both physically and mentally and we must provide them with the tools they need to live productive, independent lives. We must prioritize the services for the most mentally ill and treat those with substance abuse disorders while continuing to invest in the prevention and early intervention for all Californians.

This proposal also goes further by modernizing county housing allocations and authorizing housing interventions which are critical to addressing some of those serious health issues. Secondly, a pathway supporting this because of a pathway for quality jobs and quality services is no secret that we are facing that shortage of behavioral healthcare workers and we can only meet our care goals if we have a workforce to deliver on those needs.

This includes we're supportive including recruitment, training and retention of that workforce and particularly wanted to call out the expansion of apprenticeship programs and creating paid pathways to allow workers to advance in their careers, attaining additional trainings and certifications. And this is why we think that's 3% of the annual Behavioral Health Service Act funds are important to be allocated for that to really leverage that sort of small 30 something million dollar amount to get that $2.4 billion investment through the 1115 waiver.

And this proposal also authorized the counties to Fund additional local workforce initiatives using their local BHSA allocation prioritized for behavioral health supports. There is no magic wand to creating experience and trained healthcare workers. It takes time and unfortunately a crisis several decades in making is going to take some time and investment to overcome. And so we think that this is an important step in that direction and will likely, unfortunately continue to need more.

Finally, on accountability and standards of reporting, one of the astonishing things has been that there has been little accountability and transparency so far with the MHSA and this measure does put additional measures in place to include state oversight, accountability and ensure that that is streamlined. This proposal addresses this issue by establishing a new annual county Behavioral Health Outcomes, Accountability and Transparency Report, which will help provide both the public and behavioral health workforce more transparency in county spending with an eye towards results.

We will have more information to be able to rectify any issues on pieces where they're privatized so that we can ensure that we are not wasting taxpayer dollars. The proposal also requires county to report annual service utilization data, expenditures of the state and federal behavioral health funds, unspent dollars and other information.

And then of course the local and state planning process is going to be critical to the oversight to ensure workers are at the table with county administrators, community based organization, health plans and other stakeholders so we can coordinate and streamline this care and provide the support. We think these measures go a long way to providing much needed accountability and we will give the public more trust and confidence that we are delivering on the care that they're really demanding every day.

So just in closing, addressing California's behavioral health crisis is a complex and multifaceted problem and this is a proposal and this proposal is an important step to modernizing the system. The whole person approach, robust planning process, accountability of providers, and investment in the workforce are critical to delivering on the care that every Californian is entitled to. For these reasons outlined, SEIU supports this proposal and we thank you for the time.

Thank you very much. Matt and I'll trap it over to Dr. Le Ondra Clark Harvey.

Good afternoon everyone. Thank you for the invitation. I'm Dr. Le Ondra Clarke Harvey, a psychologist and the CEO of the California Council of Community Behavioral Health Agencies. Our organization includes providers who treat every population from justice, involved developmental disabilities and the entire age spectrum. In 2004, our founder worked alongside other advocates to provide critical input about shaping the Mental Health Services Act. So we're forever grateful to Mayor Steinberg for being the champion of the act.

In fact, in 2019 we met again with the Steinberg Institute and discussed how to best and responsibly refresh the act. And we shared at that time what we saw as the possibilities, including including substance use disorders, flexibilities for rural populations, adding additional funding for older adults, more FFSP funds, and greater accountability overall in how the funds were used. However, in 2019, we did not anticipate the avalanche of change that was about to come to us.

A pandemic payment reform which as of this very moment is currently threatening the financial health of our Members care, court, you name it, you get the picture. Behavioral Health has not seen this much attention by our leaders in 20 years. So thank you for the attention. Thank you to the Administration and the legislative leaders for your commitment here. But providers are simply overwhelmed. Any effort that recognizes the tremendous pressure that our Members are experiencing by phasing in implementation is appreciated because 2026 is not that far off. It's not as far off as it seems.

So we appreciate also the focus on transition to care based on history. Though we're concerned about managed care plans picking up the slack immediately and fully. So we're hopeful for a phased in approach with clear accountability, not just for counties and providers, but also for managed care plans.

Our substance use disorder providers are critical, and so many of our clients with mental health needs also have substance use disorder challenges. So the newly added flexibility for counties to determine how to use funds for substance use disorder services is quite welcome. The addition to the BHSS is also appreciated as well as the expanded parameters around early intervention are good. We encourage much more flexibility here.

I think when people hear early intervention, they think about awareness campaigns and billboards, but each county uses these funds really differently. Some to Fund specific projects for culturally diverse populations and others for foster youth and young adult interventions. And at the same time, our Members continue to worry about the tight squeeze on outpatient and crisis services funded or proposed to be funded through BHSS, especially for adult and older adult populations who are at high risk of becoming unhoused.

Workforce continues to be a critical component of all of this. I received Mental Health Services Act wet funds during my postdoc at UCLA Children's. It's what helped me get to this very chair that I'm speaking from today. So we appreciate any additional effort to support the workforce within the act or other policy changes that will bolster the act in this proposal, because without workforce, none of this is possible. I think my five minutes is up, so I'll end with gratitude and a note of caution.

Yes, it is time to it's past time to reexamine the act and it must be based on data that drives decisions and clear and achievable accountability measures. So the role of counties, providers, the Oversight and Accountability Commission, local stakeholders and community voices is critical to get this right because there is much on the line CBHA appreciates and will continue to collaborate with the Administration and the Legislature as this proposal to continue as this proposal continues.

And our chief concern is those who it impacts, the providers who are in the trenches, actually doing the work, and most importantly, the safety net clients that they serve. Thank you.

Thank you. And I want to thank both of you for just bringing the voice of the worker to us because that's incredibly important in this with burnout and the harder we make the system, the faster we lose clinicians, right? So we have to make sure that we keep our ayes on that. And again, we will continue to focus on your feedback and be able to adjust it as we others oh, I'm sorry, we have another participant at this time who is on Zoom Kim.

Yeah, thanks. Can you hear me okay?

Yes, we can. Kim. Thank you.

Thank you. Good afternoon, Chair Eggman and committee Members. My name is Kim Lewis and I'm the managing attorney and the Director of California Policy at the National Health Law Program. So NHLP is a public interest law firm that works to protect and advance the rights of Low income and underserved individuals and ensure equitable access to affordable, quality health care, including comprehensive behavioral health services.

I've personally worked on policy issues in California's mental health system for over 30 years, and the Administration's Behavioral Health Modernization proposal is intended to strengthen California's mental health and substance use disorder system and promote access to high quality and appropriate behavioral health services while also ensuring that Federal and State Dollars are maximized.

The proposal attempts to strike a balance between meeting the behavioral health needs and housing needs of Californians, with serious and moderate now on behavioral health conditions, while also requiring an ongoing focus on prevention and early intervention services, as well as promising practices and community defined practices such as full service partnerships. We fully believe that BHSA should address the needs of children, youth and young adults, and are pleased to see the recent changes to emphasize the focus on the needs of youth aged 25 and younger.

But we also want to remind the committee that behavioral health services are covered by medical and must be provided when necessary to approve the behavioral health condition, regardless of whether counties rely on BHSA funding to pay for them. Medicaid's broad early and Periodic Screening, Diagnostic and Treatment benefit is a federal entitlement for Members under age 21 and therefore a state obligation, and we feel confident in saying that those needs are still not consistently being met by county behavioral health plans.

So this leads me to what I want to focus my time on before this committee, which is the need for greater accountability and transparency. As others have said, the MHSA originally intended to augment the provision of services, supports and housing that were unavailable at the time under MediCal. And the Affordable Care Act has since transformed the MediCal program, increasing the number of members, the number of covered mental health and substance use disorder services, and CalAIM is making important reforms to MediCal as well.

Yet California still lacks a robust system to monitor and track how behavioral health funding from various resources is being accounted for. Such a system is necessary in order to ensure that behavioral health services are provided and claimed under Medi Cal and that federal matching funds are maximized so California doesn't leave federal dollars on the table.

Medicaid is the single largest pair of behavioral health services in the country, including in California, so it's essential to know how state and local funds are being utilized to deliver the required state plan and waiver covered services for medical Members.

MediCal managed care plans and county behavioral health plans are directly responsible for meeting those needs for people on medical given 88% of medical Members are in managed care and county plans are responsible for specialty mental health services and almost all substance use disorder services for the entire medical population. And DHS's role and legal responsibility as a single state Medicaid agency is to oversee medical expenditures, service delivery and accountability by the county behavioral health delivery system.

To that end, the Department needs to know how realignment funds and MHSA funds are being spent by counties to better understand how they're being utilized to meet the ongoing behavioral health service needs of children, youth, adults and older. Adults in Medi Cal and in light of the administration's BH Connect proposal, which could expand Medi Cal coverage to institutional psychiatric treatment. In certain situations, this transparency is particularly important.

We want to know whether and how much of these resources the counties are spending on institutionalization psychiatric inpatient services, ED visits, rather than services to support and maintain children and adults with behavioral health needs at home and in their community. Without such a system of accountability measures and fiscal transparency, we'll continue to raise concerns that the unmet needs of MediCal Members and lack of accountability and transparency by counties in meeting those requirements regarding quality and access to services those requirements that don't exist currently under MHSA.

The current proposal would address some of these concerns by requiring counties to always bill Medi Cal for covered services, requiring greater county accountability and transparency through additional reporting on metrics such as the allocation of each source of funding. Unspent funds, workforce quality as well as data related to behavioral health disparities and outcomes to achieve health equity.

Establishing metrics to measure and evaluate the quality and efficacy of services under medical county behavioral health delivery system and requiring reporting annually to the county Boards of supervisors on medical behavioral health utilization, quality, expenditures and other data is critical. Statewide quality and effectiveness metrics for medical behavioral health services have been lacking and are needed to demonstrate the intended impact of services, not just penetration rates that measure basic access.

Authorizing the Department to align contractual requirements by county mental health plans, substance use disorder plans, and medical managed care plans is also critical. The state should move towards integration and better coordination and alignment of behavioral health and health services, particularly for Medi Cal beneficiaries who must often navigate a complicated and sometimes duplicative system. So, in closing, the modernization of California's behavioral system is a complex task, as others have said, and it will take time and significant effort.

But the current proposal is an important starting point to achieve the needed accountability and transparency that we believe will significantly help improve access to quality behavioral health services across the state and lead to better and more equitable outcomes for California's low income and vulnerable populations with behavioral health needs. Thanks for the opportunity to testify before the committee.

Thank you very much. Questions from my committee Members. All right.

We thank you all very much. This is an ongoing iterative process, as you can all see. Again, this is just an informational hearing today. We're not going to be voting our first vote next week, but we wanted to give a chance for the senators to be able to weigh in. So thank you very much for your partnership and continuing to to be a part of this. And now the next group of stakeholders. Phoebe Bell, Behavioral Health Directors, Nevada County. Lashan Francis, senior Director, Behavioral Health Children. Now. Josefina Alvarado Mena, CEO, Safe Passages. And Dr. Mary Ann Dewan, Superintendent of schools, Santa Clara county. Welcome.

Phebe, you sat down first, so I'll let you and Phebe and I share a school. Both went to Portland State.

Exactly.

Her for her master's, mine for my PhD.

Let's see if we can get this to...I am screen sharing. Sorry, quick tech thing.

You want me to have someone else start while you're getting ready?

No, I should be good. It says I'm screen sharing. Can you guys see it up there?

Excellent. Great. Good afternoon, chair and Members. Thanks so much for having me here today. My name is Phoebe Bell. I'm the behavioral Health Director for Nevada County and past President of Cbhda. I'm here today to provide the county perspective on the restructuring of the MHSA as proposed in SB 326. MHSA has completely transformed how we deliver specialty mental health services in California over the last 20 years for the better.

There it goes.

MHSA has given us the opportunity to make true investments in prevention, early intervention, and to build a more robust continuum of outpatient services. In fact, an independent, peer reviewed study out of USC found that thanks to the MHSA, we've prevented over 5500 deaths by suicide. Today, the MHSA has become a core source of funding for a broad range of services. It makes up one third of our state dedicated funding streams and is a crucial source of match for medical.

It's also transformed how we deliver care by requiring us to more meaningfully engage our communities in building out services. Not a penny can be spent without local input and sign off. Counties are appreciative of the author and the administration's.

Acknowledgment of the many outstanding issues and challenges we face as a public safety net for mental health and substance use disorders in bringing forward SB 326, including an MHSA funding structure, which is overly restrictive at times and limits our ability to pay for standalone substance use or Sud conditions, lack of access to housing for our clients, and the opportunity for more transparency about our services and expenditures. The public system is open to being held accountable for outcomes related to how we do our work.

I also want to acknowledge the various amendments that went into print yesterday. Several of these address concerns raised by counties and other stakeholders, and we appreciate the opportunity for further engagement on some of our outstanding concerns while we're still working to digest the extent of the amendments. I especially want to thank the author and the Administration for many of the improvements, including recognizing the needs of smaller counties such as my own, and our unique circumstances.

So what I'll share today reflects work done across all counties to analyze the impacts of the proposed SB 326 restructuring as put forward prior to yesterday's amendments. But I'll try to acknowledge those where I can. So first, in this look at the MHSA buckets, we can basically see the biggest change to how we'll be funded is the new added requirement those shades of purple, which is the housing requirement, adding one third of our funds being used for housing.

And while we initially estimated that our prevention and early intervention funding would largely be maintained, the shift of funding to the population prevention category to the state would create additional shortfalls that aren't represented here. However, the most significant shift would occur in that orange category called General services development, which today consists of backbone programs such as outpatient services, crisis peer support, and recovery services that help our clients achieve stability and avoid the need for crisis full service partnership and housing services.

This view brings into play the addition of substance use disorder funding, the potential impacts that would happen if we divert existing funds to add SUD capacity, and I do want to highlight that in 2019, CBHD and CSEC worked together on a joint set of MHSA reform principles, which called for using MHSA more flexibly for SUD only services. So we're very much aligned with this goal.

It's incredibly important, and as currently drafted, the Bill would require us to divert funding that today supports mental health services in order to build out new Sud services. We understand today's amendments may address some of these concerns, for which we're grateful. However, we think it's important to acknowledge that in many cases, funding SUD services appears to remain a requirement without additional new funding to ensure currently funded mental health services can be sustained.

In this view, counties worked with CBHD on how to model our existing programs and services and how those would translate to the new funding categories in a more granular way. Here you can see an example of a large county, which is San Joaquin, a medium county, which is Monterey, and a small county which is Nevada, my county, using current expenditures by category. And again, you can see the addition of the lavender housing category and the pretty significant decline in what was called General Services Delivery.

Sort of that broad bucket category becomes BHSS. Again, what we see is a loss of funding across that General services bucket. That's anywhere from 50% to 80% for counties. These services are also largely matchable through medical, which would increase the impact of the losses to our communities with the related loss of federal funding match. Or to say that another way. If we cut $100 of MHSA from a program, we have to cut $200 of services because of the loss of the match.

So here's a little bit of a deeper dive into what it looks like in Nevada County, my county. It looks like I'll need to move about three quarters of a million dollars out of my $4.3 million FSP program in order to meet the spending required in the other categories. And this would be if all the funding were only spent on mental health services. If I added in SUD specific services, that would be more impactful. We would also likely lose about $1.3 million in medical revenues.

In addition, this photo is from our peer respite program that we operate with MHSA GSD Dollars. It's staffed entirely by peers. It's a six bed house where people can stay for up to 28 days, often avoiding hospitalization or using it as a transition space after an inpatient stay. It's an incredible program beloved by our community. It costs us about $750,000 of GSD dollars that are at risk, given the cuts we will need to make.

In the end, our primary concerns are with the potential loss of core funding for outpatient, crisis and recovery services, along with now prevention dollars, and how strict funding categories actually may have the unintended consequences of forcing counties like mine to decrease funding to FSPs. Another concern we have is the inherent volatility of the tax, which the LAO has thoroughly described. Managing an unpredictable and volatile funding stream with numerous very rigid categories of funding is extremely challenging.

We believe that solving for the impacts of this volatility is a crucial reform and look forward to further engagement on this topic. Lots of specific examples of how that can play out.

But you do feel the impact. Of the volatility.

Yeah, 100%. And trying to manage that volatility to those rigid categories, you get more money than you expect, and you want to spend it on something like housing, but you can't because it'll throw your ratios off. And so you sit on the money until you can ramp up all the other pots to get to the right ratios. And so that categorical funding really impedes the ability to be adaptive.

So in summary, we believe that we have a shared interest with the state in trying to stably and sustainably Fund our services. Understanding the potential impacts of this proposal is critical to avoiding unintended harm to the system. We want to acknowledge the author and Administration for addressing several of the concerns raised by counties, including the need for rural exemptions and flexibility in how we define housing and chronic homelessness investments.

While we appreciate the willingness to allow transfers between components, we continue to be concerned about the implications of managing strict fixed percentage requirements within the state's most volatile funding source, as Senator Roth was speaking to earlier that same issue. Finally, counties are acutely aware of the need to make changes in how we are delivering and reporting on our services.

We continue to analyze the proposed changes to this part of the Bill as amended yesterday, to ensure that new compliance requirements are appropriately resourced and consistent with the goal of CalAIM to streamline documentation and administrative burden. We welcome accountability and the expanded opportunities to invest in SUD and housing services. These are causes and concerns that we have championed as well.

And we look forward to continued partnership with the Legislature and the Administration to ensure that as we make these changes, we can continue to use these funds in partnership with communities in ways that best meet the needs of our community Members and prevent unnecessary suffering, as Mayor Steinberg said, and even death for thousands of Californians. Happy to answer any questions.

Thank you very much, and we'll move on. But, Dr. Ghaly, I'll ask you to respond to the reduction in funding that Director Bell is talking about when everybody's done. Okay, I'm sorry, Ms. Francis.

Good afternoon, Chair Eggman and committee Members. Thank you. Thank you for the opportunity to address you today. My name is Lishaun Francis, and I'm with Children Now. Children Now is a statewide research policy and advocacy organization. First, we really, really want to thank the Administration for being so willing to work with us on these amendments.

We were really excited to see a number of things, primarily the set aside for kids in the prevention early intervention bucket, the aligned definition of behavioral health treatment need with that of CalAIM, as well as the expansion of the homeless population beyond chronic homelessness. So I want to flag that. My comments that follow today, they're not exhaustive because we're still reviewing the amendments. So basically, I reserve the right to be wrong.

But we do have a few we do have a few outstanding questions that arose for us when we were reviewing. The first is with the separation of prevention and early intervention into different pots operationally, how would programs who do both receive funds? For example, we have school wellness centers that have both population health programs as well as early intervention programs. Would wellness centers have to apply for funding twice?

We still have questions around the services that can be covered under early intervention and whether it's limited to early psychosis type programs. Of course, we would like to ensure that early intervention service list is broader than that of early psychosis programs. We're also noticing that with the alignment of the behavioral health treatment need definition, there's some inconsistency on how the Bill defines children and youth by age. So in some places it's under 21. In other places it's under 25.

So we really would like to take another look at that. We, of course, would want it to be under 25 and under throughout. We also have questions. We understand that there's a lot of excitement around the flexibility for counties under these new amendments, but our question is always going to be with that flexibility, what does that mean for the populations that are less seen, like children and youth? We feel this tension under the full service partnership program. We're really big fans of it.

The whatever it takes approach has been really helpful for children and youth. Currently, FSP population has about 50% of the FSP population serves young people, and we want to make sure that that remains. Lastly, I want to highlight our July letter as well as some of our suggested amendments where we requested additional set asides for kids. One of the things that those of us in the children's space recognize is that our bookend populations are often forgotten.

And when I say bookend, I'm referring to our zero to five population and our transition age youth. And that's primarily because there's no formal system that supports them consistently like schools for our school age children. So for these reasons, we're still requesting a set aside for the zero to five population within prevention. We understand that this is not current practice.

However, our experience with the MHSA in its current form is that it's been a lot of work to ensure little kids are thought of on the local level. The state, vocalizing its desire to support small children really could go a long way. Secondly, we're still requesting a set aside for unaccompanied youth under homelessness. We believe it's critical to have separate housing supports and services dedicated to youth that is designed to meet their unique needs.

I also want to point out that the state actually has a number of programs right now in homelessness that set aside funding for youth. So, for example, the Homeless Housing Assistance and Prevention Program has a youth set aside that requires local jurisdictions to invest at least 10% of their total funding to address youth homelessness. And as an FYI, this set aside resulted in a 21% reduction in youth homelessness since 2020. Frankly, those are numbers that we're really only seeing in the youth space.

So I really do love Mayor Steinberg's take on the desire for the state to set priorities for the counties. We agree, and we think it's important that the state set those priorities. We're just asking that those priorities reflect the needs of children and youth throughout the entire Bill.

We're really looking forward to continue working with the Administration, hopefully on the next round of amendments so that SB 326 can be a Bill that doesn't just keep the status quo for children, but ensures children and youth have an even greater opportunity to thrive over the next 20 years. Thank you.

Thank you very much, and I'm very proud. San Joaquin County, we are working to open an Operation Home Key for transitional age youth. Please add Dr. Dewan.

Good afternoon, Madam Chair and Members of the committee. I'm Dr. Mary Ann Dewan. I'm the county Superintendent of Schools in Santa Clara County, and I'm representing a coalition of more than a dozen education, labor, and management groups. We did distribute earlier, and Members of the committee should have in front of them a printed copy of our slide deck as well as our coalition's joint letter. The education groups that I mentioned are reflected on the first slide that is being provided to you.

We are deeply grateful to the Legislature and to the Administration for the recent historic investments and policy changes that really did increase support for youth behavioral health and is beginning to move California toward an integrated systems approach. These efforts are positive steps towards alignment and coordination between schools and health providers, which is essential from the education perspective addressing the needs of the whole child is really necessary to our success.

Research tells us that when children are hungry, when they have unmet medical needs, experiencing anxiety and trauma and stress, when they have emerging mental health needs, early psychosis, or untreated trauma, their brains cannot process information effectively, and schools must meet those physical and behavioral needs of children while also providing quality curriculum and instruction. This is why we're so pleased to support the Mental Health Student Services Act and the Children and Youth Behavioral Health Initiative, which included a specific focus on school based behavioral health services.

And I don't know if we can get the deck up, but in your packet on Slide Two referencing that these historic investments reflect that children and youth are 21 times more likely to access and benefit from mental health services when they are provided on a school campus. Providing services at school significantly reduces the many barriers to access that youth face and the unique primary barriers that youth face to mental health access, including transportation and cost, and often community stigma.

We appreciate that the Administration has restored the provision requiring 51% of the early intervention funds be spent on children and youth. However, we still note that none of this funding is protected for school based behavioral health services, and this is a necessary part of our state's whole child approach. On Slide Three, we're providing some information about our current understanding and the structure of funding.

While some have argued that Prop 63 is no longer a necessary funding source for school based behavioral health programs because new one time grants and billing options have been made available or will become available, we understand that that perspective reflects a fundamental misunderstanding of both the types of services that children most need and the limitations of one time funding, as well as the limitations of some of the vehicles for billing for school based services.

It's now widely accepted that other than most severe cases, diagnosing children with a mental illness is not best practice. While one in five California children have experienced trauma in the last three years, the vast majority would not meet the medical necessity requirement for billing managed care. Children still need services to mitigate the onset of behavioral health symptoms, to promote healthy self regulation skills, and to support their school attendance and learning.

As illustrated on Slide Three, schools have limited direct access to ongoing funds for student behavioral health and only one source of ongoing funding for tier one services: Prop 63 Prevention and Early Intervention Funds. You'll notice that this slide does not include community schools or grants in the CYBHI. That is because these competitive one time grants did not provide for ongoing funding to sustain necessary school based services, and the billing options are not yet online and will not fully cover the cost of services once they are.

PEI is therefore critical to creating that continuum of care for children and ensuring that schools are a significant part of that continuum of care. Several counties are demonstrating how PEI supports student mental health needs. Solano county currently allocates $8 million to Fund 40 student wellness centers on school campuses. LA County provides 10 million to LA USD for trauma and resilience informed early enrichment programs. In Santa Clara, nearly 20 million for school link services is budgeted.

In Fresno, the county committed $110,000,000 to build out school based behavioral health services. School based behavioral health must be prioritized within the new proposed early intervention category in order to protect these programs. Moving to Slide Four Reopening Prop 63 creates an exciting opportunity to increase school based behavioral health services and to strengthen California's efforts to build an integrated system of care for children. We encourage Members of the committee to consider these impacts on school based services in your districts and including our coalition's.

Requested amendments would significantly strengthen coordination of care and preserve necessary services. The resources linked on Slide Four provide information about why school based approaches to youth mental health are necessary and why it's essential that educators be included as the state creates an integrated system of care for children. I'd like to point out in our coalition letter a number of places where we are recommending education and education leaders and providers be included.

We appreciate the amendments to date, which did reflect one of our recommendations, but there are several others that have not been addressed yet, such as in Section 20, Section 39 and Section 41 and Section 50. So thank you all so much for your opportunity to serve as a Member of this panel, and I'm happy to answer any questions at the appropriate time.

Thank you so much. We'll move on now to Josefina Alvarado Mena.

Thank you, Chair Eggman and Members of the committee. Thank you for the opportunity to appear on the panel before you today. My name is Josefina Alvarado Mena, and it's been my greatest honor to serve marginalized communities of color and LGBTQ plus communities in Oakland, Alameda County and the great state of California. This month marks my 20th anniversary serving as the CEO of Safe Passages, a multi-service community based nonprofit organization dedicated to the social, emotional and economic well being of the communities we serve.

Our communities believed in the promise of the MHSA and its stated goals of reducing the seemingly intractable behavioral health disparities. However, behavioral health disparities continue to hinder the well being of our communities, as evidenced by the following data: In California, African American, Latinx, Native American, Asian and Pacific Islander, and LGBTQ. Plus, adults from these groups have high rates of serious mental illness, high above the state average, as seen in data evidenced through the California Reducing Disparities Project 2019 Agency Report.

6.3% of African American Californians report serious psychological distress, nearly double the rate of white Californians at 3.3%. African Americans make up 6.5% of California's population, but nearly 40% of California's unhoused population. Pacific Islanders suffer from the highest rates of depressive disorder 20% among all racial groups and the second highest rate of anxiety disorders 15.7%. Latinos Latinx makes up 39.4% of California's population and face significant barriers to mental health care.

For example, only 9% of Mexican immigrants who require counseling services are able to receive culturally and linguistically appropriate care. Nationally, native American communities are twice as likely as the White population to experience serious psychological distress 11.6% versus 5.6% and have more difficulty than White clients 10.6% versus 6.8%. Accessing mental health care. LGBTQ plus individuals face severe mental health disparities, including higher rates of mental health disorders, higher rates of substance abuse, and higher rates of suicide than non LGBTQ plus populations.

And up to 40% of California's unhoused youth population identifies as LGBTQ plus. In order to truly anchor in equity, the language of the legislation and subsequent amendments must include the language of equity. We must explicitly state that reducing racial and ethnic and LGBTQ plus mental health disparities is a goal, objective and expected outcome of the modernization legislation. We must ensure that our state and local jurisdictions are actually accountable for reducing disparities in mental health and in services to all Californians experiencing homelessness.

Over the past six years, we have been in deep partnership with the 34 community based organizations, the Racial Ethnic Mental Health Disparities Coalition, and other allies funded by the California Reducing Disparities Project to implement community defined, evidence based practices with laser focus on reducing behavioral health disparities among the five population groups: African Americans, Latinx, API, Native American and LGBTQ plus communities. The CRDP represents California's greatest investment in reducing racial, ethnic and LGBTQ plus mental health disparities.

We represent a unique coalition of over 60 local and statewide behavioral health organizations dedicated to ensuring that all Californians have equitable access to behavioral health solutions that work in the historical, cultural and community context. However, the sustainability and scalability of this effort rests with the state's ongoing commitment to addressing the historical and ongoing racial and ethnic disparities and homophobia and transphobia firmly rests with the state's political will to expand investments in solutions that work for our community.

We strongly believe the 5% Cap, now 4% Cap on population based prevention programs is both inadequate and unacceptable. The state should not abdicate its leadership on this vital issue of equity. Although we appreciate the efforts to address the situation of unhoused Californians and the recent amendments, we remain deeply concerned about key provisions of the MHSA targeted in this proposal. The MHSA is the most significant and consistent funding source of behavioral health prevention and early intervention services in California.

Without upstream investment in prevention services, the underlying causes of complex social problems will not be effectively addressed, including health disparities and homelessness, resulting in more crisis situations, interventions and even greater disparities. Research proves that investment upstream in prevention can reduce the onset of mental illness, including serious mental illness.

A recent groundbreaking study commissioned by the state on the MHSA funded California Reducing Disparities Project by the Psychology Applied Research Center of Loyola Marymount University shows that the evaluated prevention programs yielded positive financial benefits for the state of California and its taxpayers. Based on a cost benefit analysis, for every dollar invested, there was estimated return on investment of about $5. Often, the only funding for these types of prevention programs comes from PEI and the innovation components provided by the MHSA.

Please consider the following points in your deliberations: PEI services can navigate children, youth, families, and older adults out of the more restrictive systems of care, resulting in family preservation and major savings to the public. The loss of PEI funding will dramatically reduce funding for services for historically underserved, unserved, and inappropriately served BIPOC and LGBTQ plus communities. Other funding, like the CYBHI, are one time investments in California's behavioral health landscape. Solutions that work require consistent, sustained, multigenerational investment to scale meaningful outcomes for all Californians.

Over 80% of California's children in grades K through twelve are children of color and LGBTQ plus, making it absolutely essential that behavioral health solutions are culturally responsive. Significant data confirms that the ongoing amplification of behavioral health disparities, particularly among children, youth, and older adults because of the pandemic. Now is not the time to reduce life anchoring PEI services. The new amendments actually reduce the proposed 5% for prevention programs to only 4%.

I'm going to ask you to wrap up.

Thank you. We heard agency state that early intervention would scale evidence based practices. Early intervention must include community defined evidence based practices to move the needle and reduce behavioral health disparities for our communities. And currently, the governor's proposal to modernize the behavioral health system does not specifically state any commitment to reduce disparities for BIPOC and LGBTQ plus communities. We remain committed to leveraging our support and collaboration towards realizing the promise of the MHSA, including the elimination of these disparities. Thank you.

Thank you very much. Okay, now, Dr. Ghaly, could you respond to Ms. Bell and the lack of the reduction of money and being able to pull down more, if you would? You're welcome to come back up.

Because again, her point was we're going to pull, because our goal is to pull down more and she's saying we're going to pull down less.

Right? Sitting right next to you. No, not awkwardly. So I think a few points. First, as we have introduced number of new opportunities in terms of services that are reimbursable by Medicaid, there is a belief, if we spent time in each county, ability to discover some services that we fund entirely with MHSA Dollars, that might have an opportunity to bring down new Medicaid dollars. So in some ways leaving some federal financial participation dollars on the table.

Secondly, we know that just over the last 20 years that there's a number of new opportunities that maybe have historically been the responsibility of county behavioral health, that 100% we have to work on bringing health plans along, but should be that responsibility to be paid for outside of the specialty mental health system.

I think the other concept here is that that flexibility introduced in today's amendments we expect are going to allow us, county by county, to introduce additional funding from one bucket to another to make sure vital services that a, are important to the communities and b, draw down additional dollars outpatient services, as an example, can be fully met. So these tools all coming together we believe are actually not going to reduce available federal dollars, but augment them.

The last point, and I think this is a very critical one, we often talk about MHSA funding as funding MHSA program. Outside of what we talk about as MHSA or BHSA funded programs, there is a clear responsibility that specialty behavioral health at the local level has to deliver entitlement Medicaid services. So those services, whether the funding comes out of supported by MHSA funding or our realignment dollars or other funding, are entitlement services that we expect, regardless of how you look at the MHSA reforms of today, are delivered. So that obligation to continue to deliver those federally matchable services exists and is maintained and should allow for the same amount, if not additional dollars to be drawn down federally.

Okay, Ms. Bell.

Just to add on to that, absolutely agree that the landscape is changing rapidly. There's tons of exciting initiatives coming to play that will enhance our system of care in so many ways that we're excited about. And I think it's important to remember that, of course, we're always going to prioritize the mandated services and we've come to rely on MHSA to provide the services that add quality to our system, add connectedness to our community.

So like, that peer support program, not mandated, plays a big role, allows us to hospitalize less people, support people in a community setting, provide peer services. We can pull a little bit of Medi-Cal, but not enough to cover the costs. Or in our crisis system. We have a crisis Stabilization unit. It runs a $500 to $750,000 deficit a year and it's beloved by our community.

It's significantly better experience than sitting in a crowded ED with stressed ED nurses trying to figure out how to manage you and their seven other patients. And those are the kinds of things that we fear losing and absolutely understand, we want to provide a comprehensive service. We want to provide a quality service, and how to stretch the dollars to meet all these needs is the reality. It's that zero sum game approach of we're trying to do more with honestly less because we're pulling more to the state level. And so how do we do that effectively.

Do this back and forth a little bit longer. And then, Senator Roth, I want to make sure I don't take all the time away. I think a couple of responses to that. And we are obviously, we have ongoing conversations about how to not just achieve what is proposed in the Behavioral Services Act, but in no way diminish the ability to deliver culturally appropriate community driven, community based services that are beloved by the community today and give opportunity to create additional new programs that we expect will be beloved by communities tomorrow.

And I would say that as we turn every corner and look at a specific program and see where there might be fear deficits, that through support, technical assistance, understanding what other opportunities might be available, that these programs not only could be maintained but hopefully strengthened. And in some cases, we hope to take the best ideas from small counties, big counties, whichever size, and help them become available statewide. I appreciate the word fear being used because I think change creates fear often. And I think California has immunized a bit against some of those fears coming true by putting so many new opportunities on the table, building the know how and the capacity to do those are important next steps.

And it is going to be a little bit county by county determining what is feared to be lost. And how do we make sure that, given our focus on priorities, given our focus on many of the things this panel has raised which are state priorities, how do we make sure that these dollars get stretched as far as possible, inviting other entities, plans, both public plans and private plans, to pick up their weight in making sure that these services are funded. And BH-CONNECT, which I know we're just getting more familiar with, is opening even more doors to do that.

Thank you. And again, that's part of the goal, right, that we're trying to pulse things up so we can have that menu of here's how you do it, here's what you pull the funding down, and here's some models. But all your points are well taken. Senator Roth and Senator Menjivar.

Thank you. Madam Chair. I haven't seen the amendment, so perhaps my next comment is going to be OBE, and I hope so. But I have listened to the comments of the behavioral health folks about the variations in annual funding, MHSA funding, and then dealing with the constraints that the fixed ratios as they refer to them, I call them buckets, but the fixed ratios and the issues that are created there.

It seems to me, and I'll say it once again, that if we set out strong, clear outcome, expected outcomes in advance by category, with consequences, that we should be able to allow counties to, individual counties to flex the ratios somewhat or less to deal with the funding variations as we at the state level will level out that funding in whatever way we figure out to do so, to make the program work without having, and I'm not talking about the mandated programs, I think the behavioral health folks were talking about those that aren't, whether it's in housing or something else, we ought to be able to make this work. And again, the only concern I have beyond that is we're putting something in play through a ballot initiative. I think even Mayor Steinberg, Pro Tem Steinberg, mentioned that the landscape has changed dramatically since 2004 when they did it the first time.

So as the landscape changes once again and we're successful in one or more of these buckets, these categories that are state priorities and local priorities, situation is going to change, we're going to be right back here doing another ballot initiative to change the MHSA to fit the second half of the 21st century. And I don't know what the answer is, Dr. Ghaly, but I will tell you, I appreciate the fact that you have devoted so much time, you and your staff have devoted so much time to this. It's a very important issue, whatever form it finally takes, because whatever form it finally takes is probably undoubtedly going to be better than what we have now.

If I may respond a little bit first, I appreciate the acknowledgment of my effort and the team's effort. I think I just want to reiterate so many people have spent lots of time writing letters, reading letters, having conversations, not just from individuals at this table, but frankly hundreds more people who have really been there through a 20 year journey, even more than that for some and hope to be here the next 20 years and don't want to make some of the same challenging, I don't want to call them mistakes, but constraints that we find ourselves today.

So not the pro at the ballot initiatives, but certainly how do we create some flexibility by honoring, but yet honoring the intent of what these dollars are meant to do, which is activate so many of the outcomes and programs that you've heard represented here and earlier. So that's the first thing, open to thinking about how that looks and what flexibility looks like.

I think we'll talk with Leg. council about that.

Second thing is the volatility at the county level or at the state level, I think is something that isn't addressed in the amendments and has been raised not just by our county partners, but the LAO, and is worth further consideration. Don't have more to say about that now. It's not captured in today's amendments, but I think it's an important one.

On your last point and without being sort of the broken record, I do think some of the bucket by bucket flexibility that is being provided helps us without losing the overall framework out, without losing some of these really key guardrails around, what are the most germane, critical anchors of behavioral health services? Especially for those with the most severe impact, severe conditions. I think that flexibility allows for some of those shifts.

And just to revisit a question that Toby Ewing had, the 7% out of each bucket isn't 7% of that bucket, it's 7% of 30 or 7% of 35. So it's a more substantial ability to shift things around to address some of those unique, either timely issues or unique county issues that rise up through their planning process.

Thank you. Senator Menjivar.

Thank you so much. I wanted to echo some of the concerns, especially around the crisis stabilization. LA County has invested a lot in those programs, I'm pretty sure a lot of counties have, and understanding that it's not prescriptive for MHSA, but it's just the creative ways that we're approaching this, and the street teams are so beneficial right now. I wanted to echo utilizing some of the funds, being able to pull the federal fund dollars to supplement these kind of programs.

But one of the questions I wanted to ask, I'm glad you're back here is, and I forgot who mentioned it, but LAO noted that when it comes to the housing category that it could potentially miss our youth when it comes to housing our youth. So I wanted to know, Secretary, if you could touch on that, how we can take advantage of this, seeing as LGBTQ plus individuals make up disproportionately in the amount homeless youth and so forth. If you could touch on that.

Yeah, I think the first thing to say is just a real acknowledgment about some of the unique housing challenges that come especially for young people who, LGBTQ youth, former or current system involved youth, whether that's probation, child welfare, widely recognize some of the unique, not just behavioral health challenges, but housing instability, homelessness challenges that exist.

So really putting forward that that should be accounted for in the data and the planning process as the county by county prioritization of how their total funds of BHSA funds are deployed to execute on the plan. I think there is opportunity in that planning process to make sure at the county level that populations are prioritized. We believe that that is a really important table to set some of those priorities as is needed.

So we've talked about the need around older Californians and the growing need for older Californians with behavioral health conditions experiencing homelessness. Similarly for younger Californians, TAY youth that might have the same needs. So creating that latitude in the planning process at the county level we believe is going to allow for this intention to really manifest county by county.

And Doctor, my question to you, you were talking about the school based services and I remember early on I asked Director, the director regarding the school involvement and hearing you, it seemed that there needs to be more involvement. I guess my question for you is if you could expand a little bit more about, does it sound like from your perspective that schools aren't at the table?

Yes, we very much appreciate that an amendment was made from our coalition letter where we requested under Section 67 for that coordination in terms of the integrated service plan. But we had also recommended several other parts of the governance structure and input structure into the reform measure where schools were missing and the voice of children and youth in education were missing. And in our coalition letter, those are noted as part of Section 20, Section 39, and Section 41 B.

Any chance you have a small clip of what those sections are?

Sure. So in Section 20, that's the Compliance Advisory Committee. Section 39 is the Commission's Advisory Committee for school administrator and school mental health professional to be represented there, to be represented on that advisory body because it's so important that we address the primary providers of mental health services. Section 41 B would require counties to collaborate with schools in the development of their early intervention services and programs.

I saw the list, it's long so you don't have to read all that. Yeah, and then lastly, my last comment is just to echo again what you mentioned, the ages zero to five. I think this is a great opportunity to take advantage of this as we're modernizing, this is to look at just really the prevention, prevention and I keep saying it starts with your first breath, it ends with your last breath on how early we can start intervention. So perhaps how else can we take advantage of that? No need to answer secretary, I'm just putting out there.

No, and I think in the spirit of some of the comments made, what I appreciate is acknowledgment that we've made progress already in advance of today and there's opportunities to continue some of the conversations. So we're continued to be committed to that approach.

And I think also, just as people say, the blending and the braiding, right. Because we did start the new big platform backbone and being able to provide services directly in school. So we don't want to miss some of those other things that we've already created, and how do we bring them together? Where's First 5 in all of this, right? I mean, there's a lot of things to be talked about. So we're still hearing and listening and making the product better. And I think that building in that flexibility will be incredibly important in the initiative as well as working on the funding volatility. Okay, Senator Rubio.

Thank you, Madam Chair. And I think the great Senator from San Fernando Valley, I believe it is, just stated the educational piece, because I think I heard you say earlier it was part of the process, and then I hear you, but I know that I think just the way that we function, we have the amendments come out last night. And so it's really hard to read everything and understand it and there's a lot of missing pieces.

But I do wanted to add my voice to that part of the conversation because I heard you say Dr. Mary Ann, right, that there's a little bit more that can be done, but I want to be giving credit where it's due. Dr. Ghaly has said several times throughout this presentation that you will know and there's further consideration for this and that so clearly you're willing to listen. But I do want to see more collaboration in that respect.

And my heart breaks in so many ways because I think I heard someone say right now that there's programs that are not necessarily part of this conversation, they're in place and we're not going to fund it. But these programs, I think you mentioned some of the programs that you put in place that may suffer as a consequence. And being a teacher, I remember just creating programs and then funding would go away and we'd have to do away with it.

But they were so significant, even though they're not part of the conversation, part of what's mandated. But it's things that we came up with that worked and unfortunately, we'd have to do away with it. And so it's just making sure that we just keep it in mind, not necessarily we could tackle specifically, but keeping in mind that a lot of the times, even as in a school setting or any organization, you come to rely on certain funding to create programs and the expectation it's there.

And even though we're reshuffling, I would say money around, programs will suffer. So just keeping in mind that we want to keep some of those programs at work and continue to support people. But this is just a commentary, but I do want to take into account, I think, what Alvarado Mina said because there's a lot of data that you offered and it was incredibly impactful for me to hear some of the statistics and data that you stated, and I don't want to dismiss that.

So I do want to give Dr. Ghaly the opportunity to just, you know, you talked about some of the LGBTQ, but let's talk a little bit more about the statistics that she discussed in terms of BIPOC communities and just around Latinos and so on and so forth. So I won't belabor the point and just give us a little bit more on that lens and how that plays into this project.

So I'm going to confess that I didn't hear all of the comments because I wasn't in the room the entire time. But I do want to say a couple of things. In my opening, I mentioned how we believe that our North Star is a person centered, whole person approach that's equity anchored.

And I think one of the comments that we haven't had a chance to talk about today is the level of inequity and frankly challenge and disproportionality among racial groups and those who experience homelessness with severe behavioral health conditions. And I think the proposal takes that into account in a very significant way, to provide some resources that today are missing, to make sure that we can erase some of those so clear and obvious disparities.

That also said, I appreciate some of the feedback around how we may need to be a little bit more laser focused in some of the words that we use within the legislation to make sure that we are allowing for community based, community directed, equity anchored practices that have evidence behind them. We often say evidence based programs and we recognize that there's a broad swath of what might be supported by evidence and they look a little different, and make sure that those are added to the list of things that might constitute an early intervention program statewide. So, again, I think opportunities to make sure we don't miss the mark moving forward.

But that an aspect of equity that I don't know that we're spending enough time on is that around those experiencing homelessness, not just chronic homelessness, but other less, maybe persistent forms of homelessness in our communities who have some of the most challenging, not just mental health, but substance use disorders as well.

Yeah, and I would add to that, I think one of the reasons that we're doing this is because of the very issues you raised that people of color, LGBT are suffering the most. So clearly what we're doing is not right. We need to refocus and figure out how to do it to address these very issues of equity.

And I just want to finish by saying that clearly what we're all hearing today is that it's not quite its final form. We continue to hear and listen and take what everyone said into consideration and perhaps just keep an open mind. And how do we create the best product so we're not here years from now trying to refigure it out again but want to thank all the panelists because just the information you provided, your insight, the work that Dr. Ghaly did, and of course our Chair, I mean it's really meaningful. And I think that if we continue to just all come to the table, we really can have something very spectacular. We just have to have an open mind. So thank you to all of you that presented. It was eye opening. Thank you. And Dr. Ghaly, thank you for your work.

Thank you very much. I'll put on my professor hat for a minute and tell people that the first draft is the first draft, right. And it gets better with every iteration. And I think we've clearly seen this throughout the process and will continue to. We really thank you for your input and your service and the work you do every day on the ground, not just coming up to tell us about it, but the work you do every single day.

You are valued, you are wonderful partners, and we really appreciate your participation. And this isn't the end of the conversation, right? We'll keep going. We don't have our first committee hearing until next week, so, again, this was informational, we're still in the works, but I want to give the Senate a chance to hear and to weigh in, and we'll be better by the time we go to next week. Okay? So thank you all very much. Okay, we're going to turn to public comments now, and so we're going to allow a minute each here in person, and then we'll go to our phone lines. Okay?

Good afternoon, Madam Chair and members. Michelle Cabrera with the County Behavioral Health Directors Association of California, and we want to align ourselves with the comments of Nevada County Behavioral Health Director Phebe Bell. County Behavioral Health departments have become experts at braiding funding, drawing down federal matching funds through Medi-Cal, and embracing change. We remain concerned with the magnitude of the cuts that would be compelled through the fund shifts and will not be offset through technical assistance or revenue maximization opportunities. So we very much appreciate the opportunity to continue discussions with the author as well as the Administration on potential solutions to mitigate those impacts. And thank you all for the robust discussion today.

Thank you very much.

Good afternoon. Stacie Hiramoto with REMHDCO, the Racial and Ethnic Mental Health Disparities Coalition. I do want to mention that 20 years ago, Rusty Selix asked me to work for him, specifically in the area of reducing disparities. And because he is a principal co-author of this act, he said on many occasions to me that it was not just for people with serious mental illness. Of course, the MHSA serves them most, but it is also, he said, PEI, he said, is for the communities you represent.

Now, he didn't use the word CDEP, or community defined practices, but that's what he meant, because that's what that was supposed to be used for, to reduce disparities. Here's a letter with over 60 of the leading organizations that serve racial, ethnic, and LGBTQ communities. What we asked for was more than the 5% for prevention. We didn't get that. The latest versions actually cut it. We asked that PEI not be separated. You separated it still. So as far as we're concerned, the bill, yes, it's gotten better in some ways, but not for us. Thank you.

Thank you very much.

Good afternoon. My name is Susan Gallagher. I'm the Executive Director of Cal Voices. We are really, really kind of beyond shocked to see that not one client of behavioral health services was on this panel today. Not one person with lived experience, the primary stakeholders in the entire behavioral health system has been consulted today. And it's sort of the entire approach that you guys have taken with this legislation, that the Administration has taken. It's sort of like, squeeze out the people most impacted. This has been so hard to understand. We have spent hundreds of hours with whiteboards and figuring out what this legislation does and how it impacts our people, and yet you don't ever even explain it to our people. Literally hundreds of thousands of people are going to be impacted by this. The CSS bucket is not big enough the way you're doing it.

You can't open it up to substance abuse and cut it as much as you are and expect there not to be unfunded mandates and people not getting served. That is going to happen. That is a given. I don't know where you guys are going to send those people. Yeah, you have an obligation. Yeah, the counties have a mandate to serve them, but with what? Now you're taking all the money away. I don't understand it. I really don't. None of this makes sense to me.

It seems very Orwellian. It seems like you're telling us you care about equity, but yet none of us are involved in any of it. So how is that equitable? We represent thousands of mental health clients in this system and none of them have been brought to the table. It's like you guys see us as an afterthought, and that is really disgusting. It takes a lot of hubris to look at an entire community that way.

This lacks compassion, it lacks dignity, and it dehumanizes us because you don't think we're capable of giving feedback. You don't think we're capable of making decisions for ourselves. And let me tell you, we are. And we do recover, and we can recover. And we're going to be here next week with our T shirts on to oppose this bill. Thank you very much.

Thank you. Next person please.

Good afternoon. Tara Gamboa-Eastman with the Steinberg Institute, in support. For the sake of brevity, I'll just align my comments with those of Mayor Steinberg. Thank you for your leadership. Thank you to the leadership of the Administration and look forward to ongoing conversations.

Thank you.

Good afternoon. Courtney Armstrong with the First 5 Association. Thank you for your comments earlier. We're here, we're happy to be part of this conversation. We wanted to align ourselves with the comments of Lishaun Francis from Children Now. We are very grateful for the inclusion of the zero to 26 population in the PEI funding. We also continue to call for a set aside for the children zero to five.

Research shows that infant and early childhood mental health programs mitigate later mental health challenges and are truly an upstream preventative in nature. If we want different mental health outcomes among our older population, we must invest in their mental health from the beginning of their lives when the foundation of brain development are set. We look forward to continuing to work with the Legislature and the Administration to ensure that the zero to five population is able to access the care that they need. Thank you.

Thank you very much.

Good afternoon. Leah Barros on behalf of California Hospital Association. CHA represents more than 400 hospitals and health systems across California, and we're pleased to support the behavioral health modernization and everything that's happening right now, all the conversations that have been had, robust stakeholder support. And based on hospitals' experiences, we just want to make it very clear that in treating youth and adults every day in crisis, we know that reforms must focus on those who need it the most.

And because of this, CHA supports behavioral health modernization and respectfully proposes changes that would one, require counties and their stakeholders to consider the needs of those who have been placed on involuntary holds or have become conserved, and two, clarify that MHSA funds are an available source of funds that counties may use for adults who are receiving short term crisis treatment in the hospitals. We want to thank you all again for your hard work and dedication on this very important and timely issue.

Thank you. Next person, please.

Priscilla Quiroz, here on behalf of the California Academy of Child and Adolescent Psychiatry. We just want to also echo our comments from Children Now. Really appreciate we still need more time to review the language, but appreciate the administration's work with working with the children groups on the amendments and happy to see that there's a set aside for prevention early intervention. However, we still have concerns that there may be inconsistency throughout the bill in regards to the definition of children and youth.

Additionally, we want to ensure that this measure sets aside for unaccompanied youth under homelessness. We look forward to continue working with the Administration and the groups and also on behalf of the Board of Supervisors of Kern County, we're expressing concerns as outlined in their letter on August 14th. Thank you.

Thank you very much.

Good afternoon, Chair and members. Nico Molina on behalf of the Silicon Valley Leadership Group. SVLG is pleased to support the reforms to the Mental Health Services Act contained in SB 326 and the bond funding proposal in AB 531. SVLG would like to thank Governor Newsom, Senator Eggman, and Assembly Member Irwin for their leadership on this important issue. Thank you.

Thank you.

I also want to reinforce some of Dr. Dewan's comments about the importance of tier One supports on school campuses. Our administrators are observing students coming to school with enhanced needs, coming on the heels of distance learning and a period of reduced socialization with peers. ACSA is, of course, still combing through the amendments, but we really do want to ensure that the critical services such as wellness centers on school campuses might still be funded through these MHSA funds. Really want to appreciate the comments made by Senator Rubio and Senator Menjivar throughout the hearing. Thank you. We also want to caution against the reliance on CYBHI one time fundings. Thank you.

Thank you, Madam Chair and Members, Mira Morton here on behalf of the California Children's Hospital Association. We are in a support if amended position on the last version, still evaluating the amendments. I would also align myself with the comments of Ms. Francis from Children Now.

Our hospitals are generally supportive of doing more to address acute mental health and substance use disorder issues, but this help should not come at the expense of prevention and earlier intervention and the entire continuum of care for children and youth. Our Children's Hospital EDs are increasingly overrun with children in crisis. In one hospital's case, they've seen an 1800 percent increase in children with mental health crises over the last decade.

But they also strongly believe that this downstream crisis needs to be addressed with increased investment in upstream solutions and ensuring the robust continuum of care is supported. For these reasons, we're really grateful for the amendments that came out today and we look forward to working with you on the final approach.

Good afternoon. The other Kim Lewis, representing the California Coalition for Youth. I appreciate your time today and the attention. I associate our comments with Lishaun Francis' Children Now, but I did want to elevate two key pieces in this. I think the Legislature and the Administration have prioritized setting aside dollars for our young people experiencing homelessness, and I think it would be imperative that we continue that set aside.

It has ensured that we have had the attention to our youth that is needed at the local level, and that's the best way that we can guarantee that to happen. On the evidence based practices, I would caution against just limiting it to that. Our community defined practices are severely important and critical for our youth, especially those who are not in families and do not have that robust support system that's available to them. So I want to make sure that we're not limiting that for them. And thank you for your attention and we look forward to continuing working with you and providing suggestions.

Good afternoon, Madam Chair and Members, Tyler Rinde on behalf of the California Alliance of Child and Family Services representing children's service providers. We'd like to thank you and the Administration today for the new amendments in print, preserving the requirement that a majority of the spending be spent on children and youth services within the population based prevention and early intervention buckets. And then also the alignment of the eligibility for services with the CalAIM definition.

Additionally, we would like to highlight that the proposed housing component needs to be flexible enough to meet the needs of transition age youth homelessness. Transition age youth homelessness needs look very different than adults. Additionally, there are many individual level prevention services currently delivered under the PEI component that we request that the list under early intervention services be broad enough to encompass the range of life saving services delivered today. Thank you.

Good afternoon, chair and committee Members. My name is Danny Thirakul on behalf of Mental Health America and the California Youth Empowerment Network. I would like to thank the author and Administration for listening to the concerns and advocates and making some conforming changes. However, I want to first echo the concerns that we have heard from fellow peers and family Members. We stand in opposition of SB 326. The amendments proposed take a first step to including TAY and peer voices in the decision making process, and we appreciate this.

However, representation is just one factor that contributes to the delivery of supports and services that depend on the funding from the MHSA. Direct prevention services, not population based and not early intervention, are vital upstream services that should be included in the new version of the Bill. Early intervention services will still be decreased from what they are today. That decrease is more now that 10% of the BHSA funds will be taken off the top, resulting in a 5% decrease of funds distributed to the counties.

This, combined with the 30% of funds diverted for housing, will result in decreased community based services. Specifically the services thank you in the BHS bucket. Thank you for allowing me to testify.

Thank you very much. Next person please. Again, 1 minute.

Good afternoon, chair and Members. Andrea Rivera, on behalf of the California Pan Ethnic Health Network. CPEN has been open to discussions on this proposal since the very beginning, and we look forward to having continued conversations with the author, Administration and the Legislature.

Our suggestions are purely to ensure that we are reducing the negative impacts for communities of color and that they are not left behind. However, we are here today in an opposed and less amended position. I'd like to align my comments with Safe Passages and reiterate that communities of color continue to be left behind in a mental health care system that has not been adapted to fit their unique needs and does not prioritize diversity. MHSA is only one slice of the delivery system.

An SB 326's approach of only looking at MHSA and not the broader continuum of care risks leaving gaps. Recent amendments make it optional for counties to provide services for individuals who are experiencing substance use treatments. Thank you.

Good afternoon. Paul Simmons with the depression and bipolar support alliance of California. What I've heard today is a lot of really good questions and a lot of non answers. Generally, when the questions are being asked, what we're hearing is, oh, we're going to continue conversations, we're going to keep working on this. Oh, we're going to try to accommodate this. Oh, the counties will figure it out. But what I'm looking at is at the bottom line of this, what we're doing is taking $700 million away from treatment.

And no matter how you slice it, that's really the bottom line of what we're doing here, of what this Bill would do. It's Orwellian to talk about this being a modernization act, it's not modernizing anything. It may be accommodating the changes in the political environment, but not in the mental health environment. Rusty Seliks was referenced today and I think would be turning over in his grave to see his work eviscerated. Thank you.

Hello, Sarah Dukett on behalf of the Rural County representatives of California, we appreciate the county flexibilities and exemptions included in the amendments, but we are concerned with the mechanism and that additional work will be needed to streamline it to ensure counties can actually access these exemptions and it's not overly burdensome. We're also concerned that the reporting provisions will be incredibly challenging to achieve, even for the small counties with that extra bump in funding.

Additional work will be needed to create manageable reporting requirements that meet the goals of the proposal and a way for DHCS to streamline or create alternative reporting for small counties that recognize staffing resource challenges in a vastly different capacity in those counties. And finally, while we appreciate the amendments that would return withholding of penalties to the county of origin, we are still really concerned that the sanction process is not graduated and lacks an appeal mechanism to ensure due process. Thank you.

Thank you, Madam Chair Members, Jean Hurst speaking today. On behalf of the Urban Counties of California, we want to thank you and the Administration for the work on the amendments that went into print today. We are, like everyone else, still analyzing them and acknowledge that improvements have been made in the language. We do want to highlight the following remaining concerns. We do share the LAO's concern that the proposal will result in county spending less on outpatient services and crisis services.

It's not clear whether the additional flexibility in the amendments will address this problem sufficiently. Next, we share the LAO's concerns with revenue volatility and the reserve caps. I want to note that the most recent amendments reduce the reserve caps even further than the original proposal. Revenue volatility also creates issues for counties in an environment where we are penalized for not hitting strict categorical spending requirements.

We think more work needs to be done to think about how to smooth revenue volatility and not set up a continuous cycle of sanctions and penalties on counties. Finally, we would like to see additional changes to the sanctions component to include due process, such as graduated penalties and the opportunity to appeal. Thank you.

Good afternoon. John Drebinger with the California Council of Community Behavioral Health Agencies. I'll align my comments with our CEO, Dr. Le Ondra Clark Harvey. Just wanted to add a brief thanks to Senator Eggman for today's amendments. We look forward to working with the Legislature and the Administration to continue to refine the proposal. Thank you.

Good afternoon, chair and Members. Avery Hulog-Vicente on behalf of CAMHPRO California Association of Mental Health Peer Rur Organizations. CAMHPRO's founder Sally Zinman was one of the fierce advocates who persistently organized, rallied, and fought for the passage of the MHSA. And we oppose 326.

This Bill has been moving incredibly fast for the amount of the changes that have been proposed. It was drafted for submission to votes in March, yet the proposed changes were not included in the Bill until June 19, providing insufficient time for stakeholders to provide meaningful input.

In an already overburdened public system, the severe reduction to prevention and early intervention services, in addition to the elimination of innovative community based programs, will alienate mental health peer consumers, BIPOC communities, LGBTQIA plus communities, while returning largely to the same medical model of county services within full service partnerships. Over the last few months and years, the mental health community has been met with continued...thank you.

Thank you, Madam Chair and Members. Doug Subers on behalf of the California Professional Firefighters, we have the honor of representing nearly 35,000 professional firefighters and EMS personnel statewide. We're pleased to be here in support of SB 326. We applaud the Chair, Assembly Member Erwin, and the Governor on their work to modernize the behavioral health system. Our Members are in the field every day seeing individuals that are experiencing behavioral health crisis and mental health challenges.

And all too often, our members provide care and comfort and take a patient to another site to hopefully get definitive care. But all too often, that system is failing them and they are back in the community experiencing those ongoing challenges. CPF has been before this committee working on efforts around community paramedicine to connect the patient with the right care at the right time.

We need to ensure that the entire system is robust so that initial care turns into ongoing care and gets folks the care they need. The last two points, we appreciate the focus and effort on workforce development and pre apprenticeship and apprenticeship programs. We think that's going to be really helpful and strong. And finally, we do appreciate the work on oversight and reporting because we think that's important as well. Thank you.

Good afternoon, chair and committee Members. My name is Karol Swartzlander. I'm the Executive Director of the California Commission on Aging. The commission serves as the principal advocate for older Californians and advises the Governor and Legislature, federal, state, and local agencies on programs impacting older adults. We applaud the Governor and legislature's attempt to improve the behavioral health system of care and improve residential settings options.

And while homelessness, for example, is experienced among all age groups, it's important to highlight that the age group that's the fastest growing population of those experiencing homelessness for the first time is folks aged 50 and older. And individuals aged 65 and older have the highest rates of suicide in the nation. So we would really like to encourage the committee to consider the needs of older adults as a unique segment of the California's population.

For example, we appreciate the amendments that added a representative, someone representing aging and disability organizations, to the Oversight Commission. However, we would recommend that you add two distinct seats, one for aging and one for individuals with disabilities, because the behavioral health needs differ among those populations.

John Lee. Before Prop 13 I was a county mental health administrator and was the Short Doyle Operations Subcommittee chair for the California Council of Mental Health Directors. The only person that spoke the truth was the Nevada Director. And when she put her budget up there, you saw the loss, you saw the cuts. Dr. Ghaly is talking magic. He can put money in three categories at the same time. It's not what he's doing. It's not what translates into real people at the bottom. We don't have enough people in the workforce. Care court is going to take away people from mental health now. Placer County's licensed people have 30% vacancy rates. The county mental health program cannot afford to do the changes that you're proposing with 326. You need to have program evaluation you don't.

Hello. My name is Cristopher Bunnell I'm representing the San Joaquin Pride Center from Stockton, California. The very nonprofit the Honorable Susan Eggman assisted in bringing into fruition. At the San Joaquin Pride Center, we currently are funded mainly on CRDP from the California Reducing Disparities program that was talked about by Josefina from Safe Passengers, along with Stacey.

Today, I come before you to address the matter of utmost importance of prevention and early intervention for mental health at the LGBTQ community. The struggles they face are often born from discrimination, prejudice, and misunderstanding, and have long lasting effects on their well being. I want to reiterate the concern around funding streams falling away from preventative and early intervention.

Moving funding away will limit the community resources we were able to provide at the San Joaquin Pride Center, providing from clinical services, LGBT community, trans care, including resources and legal name changes, as well as creating overall community for the San Joaquin Pride Center.

Thank you very much. Okay, seeing nobody else approaching the mic at this time, we're to go to the phone lines. We're just going to take 15 minutes of phone comments. So 15 minutes, we're going to shut it down Moderator and again, people are still welcome to write, to call. This is still a process, so you'll still have time to offer feedback. Moderator, are you there?

Yes, thank you. For public comment, you may press one, then zero. Thank you. Callers, 1 minute. Line 58, your line is open.

Good afternoon, Chair and Committee Members. My name Ingrid Salazar and I work with Central Valley Immigrant Integration Collaborative in the Central Valley. I am calling to express my opposed, unless amended, position on SB 326.

Communities of color continue to have the highest unmet mental health needs in California. Despite county and community efforts to address gaps, racial disparities remain stubbornly embedded and unchanged. We believe a true modernization of mental health requirements enhancements across the continuum of care, not just MHSA, and also the use of voluntary services to avoid creating additional gaps for communities of color. MHSA is only one slice of the delivery system.

SB 326 and its approach of modernizing only the MHSA, without regard for the rest of the delivery system, risks leaving thousands of Californians worse off than before. With that said, we strongly urge the legislator to consider these amendments to ensure resources are delivered to communities that need them the most.

Thank you very much. Next caller, please.

Thank you. Line 13, your line is open.

Yes, this is Erica Hoffman with the California School Boards Association. I would first off like to say thank you for the amendments that were just put into the Bill last night. They do address some of the concerns we had. I would align our position with Dr. Dewan from the Santa Clara County Office of Education. There is a strong need to ensure that schools are included in the local program discussions and advisory groups. And I would also like to align with the comments of Sirette Kaminsky with the Association of California School Administrators. We look forward to more amendments and more discussions on this. Thank you very much for your time.

Thank you very much for your call. Next caller, please.

Thank you. Line 65.

Good afternoon. This is Rebecca Gonzalez of the National Association of Social Workers, California chapter. I want to thank the committee for this hearing, and I want to acknowledge that this is a work in progress.

I want to associate and support the comments from Josefine Alvarado Mena and uplift that the MHSA should center their goals on reducing racial, ethnic and LGBTQ disparities. I appreciate that Secretary Ghaly said the act would be centered in equity, but it could be further clarified. It was also unclear to me if community based evidence practices or CDEPs are still an accepted practice under the proposed reforms.

Under the California Reducing Disparities project, it was shown that CDEPs ensure that certain cultural practices are incorporated to meet the needs of different communities. We are also concerned that prevention has been separated from early intervention and are not sure why that was done. Also concerned about the reduction from 5% to 4% for the prevention bucket. Thank you.

Thank you. Next caller please.

Thank you. Line 30.

Hello. Yes. My name is Joel Baum, and I just want to say that if the vision for the governor's revamp is truly about providing the services to those most in need, there are no groups more in need of resources than those BIPOC and LGBTQ communities as alluded to by Ms. Alvarado Mena. The revisions to date, including the most recent amendments, demonstrate little, if any, acknowledgement of their lived experiences.

This includes no language related to community defined evidence, practices or CDEP approaches that have been demonstrated to most effectively meet their needs. Sadly, many of the disparities these communities face are grounded in the failure of county based services to address them in culturally appropriate ways. This failure arises in many ways from a fundamental lack of trust that their experiences, let alone their mental health needs, will be authentically addressed. CDEPs evolved by, from and for these communities.

CDEPs also offer a pipeline for future providers that are being called for in the revision. Please restore the funding for prevention back to at least 5%.

Thank you, line 71.

Aloha and good afternoon. My name is...I am of Pacific Honor descent and I work for Asian American Recovery Services/HealthRight360.

Our project is the essence of Mana program, which is a culturally specific program that is part of California Reducing Disparities aims to reduce stigma and increase connections of mental wellness...mental health disparities for our communities and being one of 35 IPTs...we have been able to...stigma around mental health conditions and other taboo topics. Also recognize symptoms and risk factors and resources of our culture specific programming.

Our Pacific Islander Village let me read that our Pacific Islander Village strongly supports the comments of Josefina Alvarado Mena regarding our underserved communities and continuous needs to weave this mat of in...California...which means thank you... for your time.

Thank you very much. Next caller please.

Line 74.

Good afternoon. My name is Lueni Masina, representing the California Reducing Disparities Project. I am calling in strong support of the comments made by Josefina Alvarado Mena of Safe Passages. Thank you.

Good afternoon, Chair Eggman and committee Members. My name is Andi Liebenbaum on behalf of the county of Los Angeles and we sincerely appreciate your work addressing behavioral health and the thoughtful perspectives presented today. Like many here, we're still carefully reviewing the amendments to SB 326 in print last night and we look forward to working with you, the Assembly Health Committee and our county coalition partners on additional amendments and next steps.

We appreciate the administration's efforts thus far, we appreciate your leadership and we will remain actively involved to get SB 326 to a place where we can successfully implement this important effort. Thank you.

Thank you very much. Next caller please.

Line 32.

Yes. Thank you, Angela Vazquez on behalf of the Children's Partnership, the Children's Partnership wishes to thank the Administration and Senator Eggman for their curiosity...impact of these modernization efforts, especially those from historically marginalized communities.

We're still evaluating the amendments, but are pleased to see set asides for children and youth put into the Bill language, and we applaud these efforts to avoid...unfairly the needs of children color against the inseparable and politically potent needs of adults with severe mental illness. In alignment with the comments made by Lishaun Francis, we do hope to make the conversation around transition age youth and as well as getting great clarity around preventive and tier one...Thank you again for continued dialogue...partnership on Children and Youth.

Thank you very much. Next caller, please.

Line 56.

Izzy Swindler, on behalf of Mayor London Breed of San Francisco and the City and county of San Francisco in support and want to thank the author and this hearing in general for the work on this issue. Thank you.

Thank you. Line 42.

Hello? Can you hear me? Yes. Okay. I'm Douglas Dunn, a Member of NAMI Contra Costa and the parent of a severely mentally ill loved one. Very briefly, I personally oppose this Bill unless further amended along the lines of especially housing wasn't really talked about. If subacute care housing is left out of the bond measure included with this, it will mean a devastating effect throughout the state for the Ram Corporation getting 2700 beds and it's causing terrible problems here in Contra Costa County. Thank you for your time.

Next caller please.

Line 61.

Dear honorable state Senators and Chairwoman Eggman, I'm Fontana Mayor Acquanetta Warren. On behalf of the city of Fontana, I'm here to express my strong support for SB three, two, six which will help reform the Mental Health Services Act. California is facing a confluence of crisis homelessness, mental health and substance abuse. As you know, there are over 40,000 homeless people with mental health issues and many are veterans who bravely served our country.

It's long overdue that we modernize our approach to serving fellow Californians who are unable to help themselves. Our cities and communities are on the front lines every day and we need a bold action now. In the city of Fontana, we are working with our federal partners to build the region's first homeless prevention center. And we hope in the future, we can partner with the state to expand those services. For these reasons, I support SB three, two, six. Thank you for your vision, Chairwoman Eggman, and the rest of our great senators. And this is my opportunity to tell you how much I thank you for this deal.

Thank you very much, Mayor. Next caller, please.

Line 68.

Good afternoon, Rachel Velcoff Hults, Center for Youth Law. We're aligned with comments offered by Francis at Children Now and other child advocates who have spoken about the importance of ensuring dedicated funding for children and youth from their earliest months and years through their transition into adulthood, ages zero to 25, and ensuring that...process. We are still reviewing the details of the amendment. They raise questions, but we want to say that we...to concern...and the inclusion of set aside for children and youth. We believe that...both address the homelessness...and meet the health needs of its children across a broad spectrum of needs. Thank you.

Thank you. Next caller.

Hi, my name is Andrew Lee with the Southeast Asian Resource Action Center SEARAC. We oppose three, two, six, unless one, address divestment away from prevention services, two, incorporate...equity and cultural language to be appropriate care, three clearly defined speed ups and early intervention services, and four, push to add speed ups as a medical benefit. We believe these are really necessary changes. Thank you so much.

Thank you. Next caller, please.

Line 72.

Good afternoon. Deb Ross with Disability Rights California. First of all, I want to align my testimony with Cal Voices. We're very disappointed that there is no client witness being heard from on your panel. Second, we think there may be some good stuff in this Bill.

We're still trying to digest the amendment, but we do oppose the Bill, most importantly because of the way it's been put together and is proceeding. This is a massive rewrite of something created by the voters, and this was drafted largely behind closed doors. The Administration did not meet with us and other people with disabilities, and we're just disappointed. So that's all I would say about that. Thank you.

Thank you. Next caller, please.

Line 75.

Hello. Thank you. Sorry. Hi, my name is Marcelle Valdez. I am a case manager at Asian American Recovery Services in San Mateo County. Our programs serve the AAPI community in our population, in our community, providing mental health and AOD prevention services which will be negatively impacted by the proposition proposed amendments. We support the comments by Josefina Alvarado. Thank you.

Thank you very much. Okay, and this next caller, you'll be our last caller. Go ahead, please.

Well, Madam Chair, we have no further comments in queue.

We timed that perfectly then. Okay, thank you very much. Moderator and thank you for everybody coming today and participating again. We'll see you again next week when we have our first Assembly hearing. We thank you for your input and your participation, and to the staff for their work today. This informational hearing is adjourned.