Assembly Standing Committee on Health

Good morning, everyone, and welcome to the Joint Assembly Health and Housing Committee's informational hearing on the Governor's proposal to modernize the behavioral health system in California. I thank you all for being here. I'm going to start things off with opening comments from today's co chair and chair of the Committee on Housing and Community Development, Assembly Member Wicks. Thank you.

Thank you, Dr. Wood, for your partnership on this hearing and your staff who have worked tirelessly to organize this hearing and analyze the complex policies underlining this proposal. Homelessness is one of our greatest moral challenges of our day, and it's particularly challenging here in California, where we have one of the highest homelessness rates in the country. A key cause of homelessness is a lack of affordable housing, and for many people, an affordable home is the medicine that would solve homelessness.

For some, though, the medicine is more complex, and for some, it's incredibly more complex. They may require intense behavioral health or substance abuse disorder treatment services, coupled with stable housing to exit homelessness and continued wraparound services in a supportive housing environment to maintain stability long term. And some of those folks need those services for the rest of their life. For many, we have talked about housing and health and the need to coordinate more closely between those two fields.

The governor's proposal represents an exciting opportunity to create that coordination. To make this proposal successful, we need to make sure it is properly targeted and resourced. Key issues I would like to explore today to make sure we are successful are the following how does this proposal fit into the state's larger response to homelessness, and specifically our strategy for providing affordable housing to those people that need an affordable place to stay to avoid homelessness? Are the housing interventions counties would be funding in this proposal comprehensive and flexible enough to get people housed?

Do we have sufficient ongoing funding for supportive services and operating costs for the units supportive housing that would be funded by the bond? As we shift funding priorities within MHSA towards housing, how will existing priorities be impacted? I know that's an issue that's been raised quite a few times, and I look forward to exploring those in the conversations today.

And with that, I will turn it back to Dr. Wood to introduce the first panel.

Thank you. Before we jump to that, the author of one of the bills in this proposal, Assembly Member Irwin, is joining us today. Welcome, Ms. Irwin. Would you like to make a brief statement?

Yes, thank you. I want to thank both Chair Wood and Chair Wicks for convening this hearing today. The connection between homelessness and behavioral health challenges is significant. Among Californians experiencing homelessness, nearly 40,000 have chronic mental illness and over 36,000 have chronic substance use disorder.

To address what has truly become a behavioral health crisis, Governor Newsom has proposed what would be the largest expansion of California's behavioral health care system for the past seven years, I've authored legislation to authorize the issuance of bonds for the Veteran Housing and Homeless Prevention Program, known as VHHP. I'm happy to expand this effort with AB Five three one, which will provide housing and behavioral health treatment in unlocked community based settings and provide housing for veterans with behavioral health challenges.

These investments will go even further with the proposed reforms to the Mental Health Services Act and Senator Eggman's SB 326. I look forward to today's discussion on this package, and I'm committed to working with all of you to ensure that the final package we agree on is one that produces results that Californians can see in their communities. Thank you.

Thank you very much, Assembly Member Irwin, and thank you everyone, for being here today. And thank you to all who participated in the countless zoom calls, individual phone calls, in person meetings and emails that have surrounded this proposal in the past nine weeks. We have been single focused on analyzing and drafting our thoughts on how to make this proposal the best it can be, and to be working with the Administration to ensure that we meet Governor Newsom's goal.

The proposal we are considering today will determine how our state will care for the housing and behavioral health needs of its most vulnerable populations. And it represents an adjustment and a significant shift from how we thought about it a decade ago, how we align our resources to the needs of those most severely impacted, those who are experiencing homelessness, severe mental illness, and debilitating substance use disorders.

This proposal addresses the challenges of a changing world and one that will cause each of us to adapt and respond to the devastation we are seeing in our communities on a daily basis. I want to thank the Administration for the opportunity to engage in a meaningful way on this proposal and to facilitate changes that we think make the proposal better. There's no question there will be some consequences to the shifts in statewide priorities.

I believe that our task as a Legislature is to be sure they are addressed and mitigated. This intersection of behavioral health disorders and homelessness is playing out every day on our streets, in our schools, and in the smallest of rural communities and in our largest cities. The subject has stirred much debate, with strongly held opinions by many and diverse stakeholders who have tackled these challenges every day to improve the health and living conditions of our most vulnerable.

We have a very full agenda planned for today, followed by a health committee hearing on Senator Eggman's Bill SB 326. We'll take a break for lunch from twelve to 1:30 and resume again promptly at 1:30. I've encouraged Members from the two committees to attend and participate fully in the discussion and ask questions to facilitate an efficient meeting. We'll begin the hearing and provide an opportunity for committee Members to ask questions following each panel and also have an opportunity to make closing remarks at the end.

Our witnesses have been given similar time constraints, and we will be asking everyone to keep their comments within the limits. Public comment will, as always, come at the end of our agenda and will be limited to 1 minute per person. We'll also always, as always, take comments in writing. Thank you. And with that, we will have our first panel come forward. Welcome to Dr. Margot Kushel and Katie Heirdorn.

Dr. Kushell is a professor of medicine at the University of California, San Francisco, and division chief and Director of the UCSF Center for Vulnerable Populations and Director of the UCSF Benioff Homelessness and Housing Initiative. Ms. Heidorn is a Director of state policy with the California Healthcare Foundation. We will hear from both presenters and then have time for questions. So whenever you're ready.

Thank you. Thank you so much. Good morning, Assembly Member Wood and Assemblymember Wicks and Members of the committee. I am Margot Kuchel, a professor of medicine and a practicing physician at UCSF and San Francisco General Hospital. I'm the principal investigator of the newly released California Statewide study of people experiencing homelessness.

I think we've included the Executive summary in your packet, and thank you so much for inviting me today to discuss the behavioral health needs of those experiencing homelessness and the evidence base for what is needed to provide the supports for those needs. So, as background, as you know, California is home to 12% of the nation's population, but 30% of those experiencing homelessness and 50% of those experiencing unsheltered homelessness at its core.

As Assembly Member Wick said, the homelessness crisis is due to our lack of deeply affordable housing. In California, we have only 24 units of housing for every 100 extremely Low income households, meaning that we're 1 million units short of where we need to be. Every solution to homelessness must center the need for housing that is affordable for the lowest income households.

While the underlying cause is due to this dire lack of deeply affordable housing, it's also clear that those with mental health and substance use problems are disproportionately impacted. I will also mention that Black, Indigenous Pacific Islander and Latinx Californians are dramatically overrepresented in the homeless population. This disparity is not due to a disparate level of behavioral health problems, but rather to the ongoing impact of structural racism.

Solutions to homelessness that focus on behavioral health must focus on racial equity due to the well documented and ongoing racial disparities in access to both mental health and substance use treatment. However, doing so alone will not in and of itself address the democratic racial inequities in homelessness. So, as I mentioned, my team recently conducted the largest representative study of homelessness in decades, the California Statewide Study of people experiencing homelessness.

To do so, we surveyed 3200 adults experiencing homelessness selected to be representative of the state, and conducted 365 in depth interviews throughout California. Consistent with other studies, we found that people experiencing homelessness have higher rates of mental health conditions and substance use disorders than the general population. Mental health conditions and substance use can both increase an individual's risk for homelessness and also worsen during homelessness.

Two thirds of the participants in the study experienced symptoms of a mental health condition, although these were most commonly severe depression and anxiety. These symptoms ranged in severity. Approximately a quarter or 27% had experienced an inpatient psychiatric hospitalization during their lifetime, and approximately 5% had done so in the prior six months. Approximately one in three participants reported regular so three times a week or more.

Use of illicit substances, methamphetamines being by far and wide the most common, 9% reported heavy alcohol use, meaning binge drinking at least once a week. So overall, 41% reported either regular illicit drug use or heavy alcohol use during this current episode. Approximately half, 52%, reported either regular illicit drug use, heavy episodic alcohol use, hallucinations, which were reported by 12% of the population, or a recent psychiatric hospitalization. Mental health conditions and substance use disorders co occur with limited access to mental health treatment.

Many individuals experiencing homelessness, and those who don't, self medicate with illicit drugs or alcohol as a result or related to their mental health issues. Conversely, substance use can increase the likelihood of developing a mental health conditions. These conditions overlap frequently, but not always. More than half of those who report current hallucinations or a lifetime history of a mental health hospitalization reported either regular illicit drug use or heavy alcohol use.

People with significant mental health problems, significant substance use problems both need and deserve access to treatment that will allow them to thrive. For those services to be meaningful for those experiencing homelessness, these services must be paired with subsidized housing. To do one without the other is not going to be effective. Homelessness itself limits access to treatment for mental health and substance use disorders for many adults experiencing homelessness.

For instance, two thirds of the statewide study participants experienced at least one mental health condition, but only 18% reported receiving any mental health treatment or medication in the prior 30 days. One in five individuals who reported current substance use, either illicit drug use or heavy alcohol use reported that they wanted and had sought treatment but had been unable to receive it. Every person who experiences homelessness lacks housing. Therefore, housing has to be at the heart of any response to homelessness.

Despite the high prevalence of mental health and substance use problems, many who are homeless will not require behavioral health support. Many will require housing support alone in the form of housing, navigation and either short term or likely long term rental subsidies. In our study, the median household income of individuals in the six months prior to homelessness was only $960. While people were homeless, that income dropped to $400 a month.

Over half of those who entered from homelessness entered from housing that we called in a non leaseholding environment. Where they were doubled up or living without formal leases. Among those with leases, the median housing costs were $700 a month, an amount that is both unaffordable for extremely Low income households and, frankly, difficult to find in California, where the median rent is $750 a month. In many regions of the state, it's even higher.

And when we asked participants all participants, about their barriers to exiting homelessness, nine in ten indicated that high housing costs were a major impediment. Essentially, all Californians experiencing homelessness need housing and income supports to support their transition back to permanent housing. But those with complex behavioral health conditions will require more than just housing to end their homelessness and improve their health. They require both ongoing housing support and ongoing behavioral health support. Providing one without the other will not meet their needs.

For those who face behavioral health challenges, we know what works to end their homelessness. For the vast majority of those with homelessness and significant mental health or substance use challenges, the solution is to provide subsidized housing offered on what we call a housing first basis with voluntary services that match the individual's level of need. Permanent supportive housing.

So, subsidized housing with paired voluntary supportive services has been shown not only to end homelessness, but also to reduce chaotic use of healthcare services, increase the uptake of mental health and substance use treatment. The key to effective permanent supportive housing lies in providing both subsidized housing and sufficient and appropriate supportive services and to center client choice. Permanent supportive housing provided on a housing first basis creates a recovery oriented culture that puts client choice at the core of its provision of both housing and services.

When housing is linked to high quality voluntary services, the evidence shows that we're able to meet the needs of the majority of those with significant baby or health disabilities. For instance, New York City's Pathways to Housing Program provided immediate access to housing and linked high quality services to individuals with severe psychiatric disabilities. After five years, 88% of these individuals with severe behavioral health disabilities who were randomly assigned to the housing option with voluntary high quality services remained housed.

In Canada, the Shea SWA project provided permanent supportive housing to thousands of individuals across five cities. They provided individuals with severe mental illness, many of whom had co occurring substance use disorder housing, with one of two robust service models that they assigned depending on the client's need. Shea Swad demonstrated that upwards of three quarters of individuals remained stably housed.

And our own research in Santa Clara County showed that permanent supportive housing with intensive case management successfully housed over 90% of the most behaviorally complicated individuals with chronically homeless and kept them housed. Those who were housed remained housed for over 90% of their nights for many years. The key to these successful programs was the fact that they adhere to the principles of housing first and that they had robust services designed to match the needs of their tenants.

In Shea SWA, they risk stratified clients to one of two models of care assertive community treatment for those with the highest level of need and intensive case management for those with moderate need. Assertive. Community treatment is an intensive intervention. It pairs teams led by psychiatrists and includes peer support, case management, and other team Members who have a relatively small caseload.

Intensive case management, while less resource intensive, involves master's level, behaviorally trained clinicians, such as social workers leading a team with Low case ratios one to twelve, one to 15. In our Santa Clara study, we relied on this model with a Low caseload. High quality care models such as assertive community treatment and intensive case Management are the gold standards of care for those with complex needs. However, in California, many who currently would benefit do not receive this level of service.

Many of those with chronic homelessness and severe behavioral health needs who are placed in PSH do not receive this level of ongoing behavioral health support that they require to thrive, and many receive neither housing nor supportive services, leaving them homeless. Our team recently conducted an analysis of healthcare and criminal legal data from 1700 individuals with psychosis and evidence of either a 51, 50 or four more urgent or emergent visits for individuals with severe mental illness in a California city. 70% of these were homeless.

Among those who were homeless, fewer than half had been assessed for coordinated entry priority status. And of those who were assessed, only two in three were prioritized for housing, meaning that only one in three of these high needs homeless individuals with evidence of severe mental health illness in crisis were prioritized for PSH. Among those with the most complex behavioral needs, only a quarter received intensive case management.

There is a spectrum of community based care options that can meet the needs of most people experiencing homelessness with severe mental illness. When PSH is paired with high quality support services that meet their needs, the vast majority will thrive. A small proportion of those with the highest Acuity behavioral health needs will need support that goes beyond what can be reasonably provided in PSH. Even with the most robust models of services, these services should share many of the attributes of high quality, permanent supportive housing.

Community based with client choice models such as behavioral health residential care facilities may be able to provide this additional support. We have both the ability and the responsibility to design responses that allow individuals to live in the community and to thrive. People's needs may change with time, and our response to those needs should change as well. But our failure to provide housing and appropriate services should not confine individuals to either a life on the streets nor institutional care to have successful outcomes.

We need to invest in the solutions that are most supported by evidence, our failures to end homelessness, and a reliance on institutional cycling. Among those with severe mental illness and or substance use disorders and chronic homelessness are due to both a lack of housing and a failure to provide the evidence based level of supportive services to meet the needs of those with behavioral health challenges. Addressing this is a key to achieving a California where all can thrive. Thank you.

Thank you very much.

Good morning, Chair Wicks. Chair wood and see. All right. Okay, the slides work. I'm Katie Heidorn. And I'm the Director of state health policy for the California Healthcare Foundation. The California Healthcare Foundation is an independent, nonprofit philanthropy that works to improve the healthcare system so that all Californians have the care they need. We focus especially on making sure the system works for Californians with Low incomes and for communities who have traditionally faced the greatest barriers to care. Thank you for having me here.

Today, I will provide a brief overview on the incidence of mental illness and substance use disorder and on access to care. Then I will suggest some high level questions to guide how we think about what California needs in our public behavioral health systems.

First, a landscape: a lot has changed since the MHSA passed in 2004. 1st coverage there's been a dramatic expansion of insurance coverage, including both who is covered and what is covered largely because of the Affordable Care Act other Medicaid expansions and the mental health parity. Yes. Next is workforce. The work force is shrinking. People can't find a behavioral health provider who accepts their insurance, and many can't find a provider at all. Substance Use there's been a significant rise in overdose deaths.

Technological advances in the last nearly 20 years. Technology has brought us new platforms for treatment like telehealth, which is especially useful in behavioral health treatment, and the recent 988 crisis line. Next the Criminalization of Mental Illness and Substance Use Disorder For too long, our approaches to serious mental illness and Substance Use Disorder have been fragmented and too often punitive. This needs to change and finally COVID the social isolation and economic disruption exacerbated people's mental health needs and substance use.

On the plus side, we see renewed commitment across the state to better address behavioral health issues, and that's why we're all here today. Next, I'll provide some statistics about the prevalence of mental illness and substance use disorder and access to care for those conditions. Most of this data is from CHCF's Almanac collections. We published updated mental health and substance use disorder Almanacs in 2022. So relatively recently, overall prevalence rates for adults and children have changed very little over the years.

One in seven adults in California experienced any mental illness in 2019. Further, about 4% of adults experienced a serious mental illness, and about 7% of children had a serious emotional disturbance. A few more statistics not pictured on this slide people at lower income levels are more likely to have a serious mental illness or for children, a serious emotional disturbance. And black and indigenous Americans experience the highest rates of serious mental illness.

This slide shows serious psychological distress, and the two sets of bars on the left show that youth are suffering serious psychological distress more than older age groups. Their rates of distress basically doubled from 2015 to 2019, and there's general agreement that this measure got worse during the COVID-19 pandemic. It's not shown here, but there are particularly high rates of serious psychological distress for people who identify as LGBTQ. In addition, every racial and ethnic group reported an increase in serious psychological distress between 2015 and 2019.

For multiracial, that rate more than doubled. Data on substance use disorder is not nearly as complete as data on mental illness or psychological distress, but we do know that about 9% of the California population over age twelve had substance use disorders in the past year from 2019 data. Although we focus a lot on opioids, alcohol continues to be the drug that affects the most people. Over 6% of Californians have an alcohol use disorder. Of all the substances, alcohol is the biggest killer.

We also know that substance use disorder and mental illness co frequently occur together. Turning to treatment. Not enough. Californians with behavioral health needs can get treatment. Nearly two thirds of adults with any mental illness did not receive mental health services, and nearly 40% of adults with serious mental illness did not receive treatment. Please note that these are worse than national averages. As I mentioned before, California data on substance use disorder is not as detailed as mental health.

California has seen a major expansion in its public substance use disorder program since 2015, and we do know that more people are now self referring for addiction treatment than are being mandated into care. That's good. Still, the estimate is that fewer than one in ten people with a substance use disorder get care for that condition. Now that we've looked at the data and understand people's behavioral health needs, I'd like to talk about what to consider when rethinking the state's behavioral health system.

The first question is what kind of care do people receive and where do they receive it? We need to focus on peoplecentered care. The efforts we've made to expand access haven't closed gaps for black and indigenous Californians or other people of color. We need to identify evidencebased practices that are also culturally and linguistically accessible. We need to integrate mental health and substance use disorder care. For example, as a field, we now use the term behavioral health to encompass both mental health and substance use disorder care.

Much more needs to be done, including around modernizing payment. We need to meet people where they are, literally by utilizing street medicine programs and telehealth and virtual care. Finally, there is tremendous regional variation in access. We need access to be equal across the state. It's difficult work, but we need to move towards it. Our second question is about who is providing that care. This chart shows the race ethnicity breakdown of behavioral health professionals. I want to call your attention to the blue bars.

Those are the professionals who are white in most categories. White professionals are overrepresented relative to the overall population, while there are very few Latino or Asian behavioral health Clinicians compared to the overall population. I will call out that second from right is SUD counselors, the only field in which providers nearly match the composition of the California population as a whole. The solution is not just about training more clinicians, but also about how we allocate resources.

We need to use the entire range of providers more effectively through team based models and consultation arrangements, as well as investing in our community workforce. And that means our peer support count specialists and our community health workers. Finally, all provider types need training in substance use disorder, primary care providers, mental health practitioners and non clinical staff. Our third question is who is responsible for organizing and paying for that care?

One thing we hear over and over is that California has a collection of behavioral health programs and funding sources, but not a system remedying. This fragmented system is, of course, one of the reasons we're here today. Complexity is a given, but that doesn't mean it has to mean confusion.

We need to engage people with lived experience in this system to make sure that we're planning and is responsive to individual and community needs, including relationships with programs that administer housing, food support, parole and probation, aging, education, and others. In addition to knowing who is responsible, we also need to make sure they're being responsible. We need to ensure that accountable entities, including payers plans and providers, have capacity, expertise, and infrastructure that they need to manage the care for which they're responsible.

Finally, we need to think about how we pay for behavioral health services so that financial incentives align with the outcomes that we want. That means that if we want a behavioral health provider or a managed care plan to provide whole person care, we need to design payment systems so that they have a reason to do that. And finally, our final question for consideration how do we know how we're doing? We measure a lot of things in behavioral health, but we can't say how we're doing.

We need to invest in data capacity at all levels of the system to improve quality measurement. This MHS redesign with aligned efforts in Medi Cal gives us a generational opportunity to create a comprehensive behavioral health quality strategy for California. This would include much better measurement of access to care, measuring patient outcomes, not just processes. And we need to measure the same things across all of our systems, not separate measures for separate funding sources.

Finally, we need to present this data in ways that people, all of us, can use with that. Thank you for having me here today. Happy to take any questions.

Thank you very much. Move on to our committee, people who have questions or comments.

Thank you both for your very informative presentations. There was a lot, so I just wanted to kind of talk a little bit more on the workforce, because that's one of the big issues. One of the things you mentioned was, how do we upskill primary care providers to be able to give that treatment? How would we go about doing something like that? We have the medical board that kind of dictates what primary care providers do, but they're meeting people all the time, and if they can identify or at least be able to talk about it with the person in front of them at the time, that would be very helpful.

Yeah. Thank you. Ms. Waldron I'm happy to take it from sort of a broad level and then hand it over to Dr. Kushel. The state has invested billions of dollars in all of our different workforce categories and also has created some opportunities, like investing in telehealth and in street medicine and our Medi Cal program, to really meet people where they are as well as investing in community health workers.

So it's really all about that as well as major investments specifically in the behavioral health workforce that we expect to roll out over time. And so it's really important to not only have that money there and that commitment which is already there, but also to also have that implemented. And it takes some time to do that. And so I know our foundation is very engaged in watching that and making sure that all of that happens and it's really necessary to have that investment upfront.

And as I said, it's really important to think about the entire continuum. So it's not just primary care, it's specialty care, it's behavioral health care workers and it's also the people who are getting out into the community, our community health workers, our peer support counselors, et cetera. So it's not just upskilling people, it's investing in that entire continuum of providers.

Yeah, thank you for that. Such an important question. I think there are a few things that come to mind once it's both our physician and our nurse practitioner and physician assistant workforce who really do a lot of the heavy lifting here. It has been relatively hard to get funding, for instance, for addiction treatment fellowships for both at the physician level and at the nurse practitioner advanced practice provider level.

These programs can really provide transformative what you do is you get a group of people who really become experts in this and leaders and then they become the trainers to support someone like me who didn't go through one of those fellowships but get sort of trained by my colleagues who did. And then there's always a line for me to call. So I think that's a really concrete step. I want to just emphasize that the disparities in substance use treatment by race and ethnicity are really glaring.

That, for instance, overdoses in the black community are rising much faster and since 2019 have surpassed overdose rights in the white community. And there has been a variety of really well done studies in the last few years that show that only about 20% of people who qualify get treatment to medication opioid use disorder, which is gold standard life saving treatment. So we're only getting about one in five people. And when you look at those data, if you are black or Latinx, you are significantly less likely.

So the other thing is to invest in a diverse and culturally appropriate workforce. Things like the prime program throughout California that trains physicians who commit to working in underserved areas. Other programs for both the nurse practitioner and physician workforce that can help us diversify that workforce would also be so I would say it's both. Investing in the training program small investments to train a group of leaders can go a very long way in sort of furthering the message.

And then once we're in primary care, as someone who practices primary care and does a fair amount of addiction treatment in primary care, it does take additional resources. So having those peer case managers, the social work and behavioral health supports right there in primary care can really help us because we've often have 15 minutes appointments, which is enough for us to prescribe the life saving medication and not enough for us.

So we really need to work hand in hand with our behavioral health providers when they're colocated. It makes all the difference in the world.

Just a quick follow up, if I may. I know in the past a physician needed to get suboxone certified or whatever through CMS. Is that still required or how would CMS also kind of integrate with everything we're trying to do?

Fantastic question. In the past year they X'd the X, so we no longer, hooray, need that X license, which is really terrific, but really interestingly that happened, and we haven't seen an uptick in prescriptions. So to me that felt necessary but not sufficient. And what is sufficient as someone like who is a suboxone provider is having that call a friend lifeline to increase all of our confidence to do this.

I'm so glad that that requirement went away, but we haven't actually seen it unleash a lot of new prescriptions. So I think it's a matter of increased training, warm lines and other support and that colocation of services to really move the needle.

Other questions, Dr. Weber.

Thank you both so much for your presentations today. Just two brief know I see a lot in studies where they talk about going out and doing survey of those who are homeless or unsheltered and they ask them about mental health challenges and things like that. In your study, was there any differentiation between whether or not they actually had a mental health diagnosis prior to becoming homeless?

That's another terrific question. So we asked folks, we did sort of symptom scores knowing that so many people don't have access to treatment that they might not have even gotten a diagnosis, but we try to ascertain it. And for instance, looking at things like a psychiatric hospitalization, which is a decent measure of a more severe, complex problem of those with a mental health hospitalization in their life, which was about a quarter, 27% 56% had had that first hospitalization before their first episode of homelessness.

So a little less than half had had that following at least their first episode of homelessness. We asked people with their substance use problems how it had changed during this episode and it was actually really interesting. It was a pretty much an even split overall. About a third said during this particular episode of homelessness it got significantly worse. A third said it hadn't changed, and a third said it got better. That split a little bit by who they were.

The young adults who were homeless were much more likely to say that their substance use had gotten significantly worse during this episode of homelessness. The parents and homeless families were much more likely to say it had gotten a lot better. And the single adults, the adults 25 and older without kids were much more sort of like, some said it got worse. Some said it got better.

Okay, thank you. So looking at your report, when you talk about the majority or 82% said something that they had experienced some form of mental health challenges, it's really the one fourth that you were looking at, and then half of that one fourth had actually experienced it prior to becoming homeless.

So half of that we tried to look at sort of a measure of a very severe problem, because depressive symptoms we know get worse with homelessness. Anxiety gets worse. The amount of trauma people experienced while they were homeless was absolutely, I have to say, astonishing. 10% of everyone experiencing homelessness had been sexually assaulted during this episode of homelessness. About a third had been physically assaulted. Those numbers are really actually mind blowing among women or trans and nonbinary folks.

It was actually much higher than 10% that had been sexually assaulted. Not a surprise that homelessness itself leads to a dramatic worsening of mental health symptoms, but we were trying to look at indicators of what we might call a severe mental illness. Hard to do, but we've sort of combined the idea of having suicide attempts, which, by the way, about one in four people had attempted suicide in their life. Again, really astonishing. One in four had been hospitalized. About 14% had experienced a time with hallucinations.

These were sort of our markers for severity. And it looked like for a little more than half of folks, those severe events predated their first episode of homelessness, but usually continued, and about half those developed after they became homeless.

Yeah, thank you so much for that. I think a lot of times there's a question about kind of which came first, and there seems to be a lot of thought that the mental illness came first and then that's why they ended up. But the reality is that many of them didn't, but did develop some symptoms once they actually became homeless. Thank you so much for that.

And my other question I know it's hard because we don't really have the data to determine, but just listening to some of the things that you pointed out and the fact that we don't have people that are seeking treatment and worse than the national average, which is unfortunate and very surprising for me here in California with the resources that we have now, with the money that we're putting towards mental health care. Do you think that that is enough?

I don't know that there's ever enough. Right. We want the highest quality, best system for people, and I think we're a long way from that. And I think the investments of the last several years have made great strides in that. A lot of the data that I was talking about is from 2019. So it's relatively recent, but we know we had the pandemic and that's just changed the landscape considerably.

And so I think in the next couple of years we'll be able to not only track the investments at the state level, major investments in both coverage and behavioral health investments, but we'll also have better data about treatment, who's accessing treatment and seeking it, and better data on the workforce as well.

Thank you so much for that. I just wonder, when we look at the numbers of those who are experiencing mental health crisis, whether it's serious or early, we talk about preventative, especially in our youth, the funds that we have right now. And the new proposal, is it the best idea to shift some of those funds into a way that's not specifically going into treatment or preventative care. But thank you so very much.

Thank you. Anyone else? Just a couple of quick questions, and Dr. Weber got one of mine, so appreciate you asking that question. Dr. Kushel, your recent report recommended embedding racial equity approaches into homeless system service delivery. Can you talk a little bit more about the methods to accomplish that and how we should monitor our efforts to ensure greater equity in services?

Yeah, thank you for that. I think there are a few points. One is that the disproportionate homelessness among black Americans, indigenous Americans, is not actually proportional to any disparate mental health or substance use problems. So there is about a fourfold overrepresentation of the black population in homelessness.

But for instance, black folks who are homeless are less likely than white folks who are homeless to have substance use disorders because really the additional risk that they carry is exposure to racism and exposure to racism in housing markets, intergenerational wealth and things like that.

And so one thing is, when we're looking at homelessness response as opposed to behavioral health response, in a way, if the only people who get prioritized for housing are those with severe behavioral health problems, you run the risk of not doing anything about that disparate that overrepresentation. So one way is to make sure that we are providing housing resources and responses that are based on whether someone's been homeless as opposed to only based on these other problems.

And as Dr. Weber said, the longer people are out there, then they do develop those problems. So that's one thing. So monitoring exits from homelessness, monitoring how the Coordinated Entry system is working, and seeing if there's any unintentional disparate impact of who gets those services. The second thing, there was some really good research out of LA that showed, for instance, that black Americans in support of housing were more likely to be evicted than white folks in support of housing. That's a really concrete thing.

You can measure of what's going on with retention in housing once you get folks housed. So I think you want to monitor entrances into homelessness. We should be seeing a decrease in that overrepresentation. If what we're doing is working, you want to monitor exits into housing and make sure we're not unintentionally sort of favoring one group or another. And then finally you want to measure concrete things like who's getting evicted once they get rehoused.

And then finally, with this really shocking disparity in access to mental health and substance use treatment, you definitely want to measure that you are actually reaching the population that's at risk, and you're not reaching one group disproportionately to another.

Thank you. And then just briefly, a question, Ms. Heidorn. You mentioned equitable access across the state in every community now, so as someone who represents largely rural district, that piques my interest, because that is a huge challenge for us in a lot of our rural communities. So just your thoughts on this. And I also represent a lot of Native American communities as well. And as we just heard from Dr. Kushel, they're overrepresented in this.

So just briefly your thoughts on this and where we might go, because I have my own thoughts, and they're pretty strong. And so we try to embed a lot of things in that around flexibility for smaller areas, recognizing the challenges, the technical challenges, the outreach challenges, and so on. But I'd love to hear your thoughts.

Yeah, I think Dr. Wood, you just named several of the items that I would discuss. I think for the indigenous communities, for the tribal communities in particular, I mentioned at the beginning of this, we've had many changes since 2004. One of those has been coverage expansion. And so making sure that particularly people in the Indigenous community who are eligible for medical or eligible for coverage are in coverage, that there's a gap there.

And so just basic coverage, I think, is a really important place to start so that they can then access have full access to those services. As I also mentioned, workforce is key. And as you know, I really appreciate a lot of the data that HKI collects on underserved and underrepresented areas in the workforce. It's really important to make sure that we still know where collecting that data, know where the providers are.

I think that that's really important to look at who is providing these services and who's available in these rural communities and then utilizing all those, particularly telehealth, and making sure that people have Internet access so that we can, to the extent where there is a shortage, that we are using all of the tools available to us. And the investment, particularly in Medi Cal, not only in commercial insurance, but now in Medi Cal and Telehealth has really opened that up.

So making sure that we're utilizing all of the tools that we have at our disposal while we're making good on all of these investments and increasing our workforce, I think, is also very important.

Great. Thank you. And then just a final question. As it came to mind, Dr. Kuschel, none of us want to reinvent the wheel because at the end of the day it's a wheel and it's already been there. So you mentioned New York has done some things. Are there other examples of other states or other countries? You also mentioned France. So anything else out there that we should be looking at?

I think at this point that as someone who loves to do research, we don't need to do any more research on what works for this population. There are really good models of permanent supportive housing, which is housing with robust services. I think one of the challenges we encounter here in California is we call things permanent supportive housing without funding either the ongoing housing needs because those needs are ongoing and the ongoing service needs or the robustness of the service.

The other thing from both France, Canada and the US. From our study in Santa Clara, from extensive work in New York and from Canada and France is the closer the programs adhere to the models as designed, the better they are. And I think one of the ways we miss our mark is we as Clinicians think a lot about giving people the right amount of treatment for the severity of the disease.

Like if you have cancer, I'm going to give you a lot more medicine than if you have a cold. But we don't necessarily have the resources or have been doing as good a job as we maybe should in matching the services to the needs of the individual. And then we throw up our hands and we say, oh, this person can't be housed, they need to be in an institution, when that's not true at all. There really are these models of what levels of service provision work.

The Canada study. The Shea SWA study was really impressive because they basically chose people who all needed a pretty high level of service on intake. Just did a bunch of simple things to evaluate what level that they needed and they put some people in this assertive community treatment, which is really the highest level. The next people in intensive case management, which is still pretty intense, but less.

And then they saw that if they got people into the right groups, they really were able to succeed in keeping people housed. And then when people were in the highest level of treatment need, the assertive community treatment and things still didn't go well, then and only then, and it was a relatively small group of people did they say, oh, let's try something different like a residential care facility. So I don't think we need to reinvent the wheel.

I think Corporation for Supportive Housing, for instance, has a lot of data and ta on how to do this. Well, I think this is sort of known what to do. I think it's a small P policy issue of just implementing it, being sure that we are matching people with the needs. I think you'll hear and you probably have heard from some supportive housing providers feeling like they're overwhelmed by the acuity of need that they're being presented with.

And I think that's often because they don't actually have the level of services that they need to actually provide services for the people who they're caring for.

Well, thank you. That will actually conclude our panel. I just want to say thank you to both of you for your work and your presentation here this morning to kind of give us a bit of a baseline as we go further. But thank you very much. Really appreciate shade it.

Thank you, Dr. Wood. Our next panel panel three will be Dr. Ghaly, Michelle Baass, and Miles White, who will give an overview of the governor's behavioral health modernization proposal. And you all will have 15 minutes to present, and then we'll allow for questions from the committee Members.

Okay if I dive in? Great. Thank you. Good morning, Chair Wicks, chair Wood, all the Members of the committee. Really a pleasure to be here. I want to start by thanking the committee and the chairs for their ability and tenacity to dig into this issue. Behavioral health is among the most critical issues of our day. Pre COVID, the swell was real. Post COVID, the vigor is even greater. And we see that in data that comes out every month either here locally or across the nation.

Wherein 20 years ago, behavioral health was hardly on the radar, today it feels like the compass of so much of our healthcare delivery system and California has responded in clear and decisive ways. Since 2019, investments in programs have been enormous.

Last week, we had the chance to continue the ongoing conversation about the tapestry that we're creating here in California that brings a whole bunch of new opportunities together with those older existing opportunities to give us a chance to do something that's not just different, but I think really moves the needle for a number of Californians who've historically been overlooked.

Some of those programs, just to name them, cal Aim, the aspects of rate reform that are taking place now changes to medical necessity criteria for young people in our child welfare system. The community supports transitional rent, which is a new aspect that helps us knit together the housing needs and the other clinical needs of so many individuals. And the first in the nation justice initiative that counties and the Department under Director Bass's leadership, are preparing to implement. The Children Youth Behavioral Health Initiative.

The all kids, every kid, every day, every hour, every minute kind of approach to the virtual platform. The often overlooked but mighty and powerful concept of a fee schedule wherein where services are delivered in schools directly to young students that they're reimbursable not just by Medicaid, but by commercial plans as well. Kind of catapulting our ability to not just have, in theory, services, but hopefully at scale. The Care Act getting ready to roll out in eight counties by the end of the year.

A topic of lots of discussion last year, creating a pathway for those with some of the most severe needs to get the full complement of a plan that they need stronger beneficiary protections. Under DMHC, this Legislature and this Governor have advanced key pieces of legislation that look at not just access, but timely access. The ability of that Department to do routine surveys, non routine surveys, to hold accountable our health plans so that average Californians, whether they're Medicaid beneficiaries or commercial beneficiaries, are getting what they need.

A lot of work to do there, but we have the tools to really make a difference. State hospitals Department I'm really proud of for their transformation of what they've been doing, looking at community opportunities to restore and be supported, not just state hospital solutions. The model Medicaid managed care contract that is really getting started implemented starting in January. That Director Baass's Department is working hard with Medicaid managed care plans across the state to make sure that behavioral health isn't an afterthought. That that requirement to focus on mild and moderate services is real. That we hold them to account.

The workforce programs that Katie on the prior panel referenced at HKI looking at not just how do we get more of what we already know, but how do we build new classifications, whether in schools for young people, for older Californians. The 988 system that is rolling out and a number of people are working on to make sure we have a thoughtful, well connected, no one falls through the cracks type of crisis system.

And lastly, the Behavioral Health Connect proposal that is being prepared by the Department of Healthcare Services to go into CMS later to provide more local flexibility around behavioral health, push the envelope on not just focusing on those institutions, but how do we transition people out of those institutions into meaningful community based care, which is frankly, the object and point of the conversation today, whether you look at the bond part of this or the Mental Health Services Act reform.

Also want to say that the equity anchor in this proposal is real. There isn't a thoughtful discussion on behavioral health that doesn't end up centering around equity, the disproportionality, the real differences in who's impacted and who's getting service and access.

I think elements of our planning process that are proposed in this proposed change to MHSA turning into the Behavioral Health Services Act underscoring one of the points that the prior panel made as well, this broader view of what mental health has become, that it's connected deeply to substance use disorders. And frankly, we talk about integration of behavioral health as mental health and substance use disorder, but let's not forget that important integration with the rest of the healthcare delivery system.

And I think this propels us in that direction for sure. I think that ability to use the equity lens to not just talk about it, but to require investments in investigation and how we're delivering and reducing disparities, what does the data show? Not just can we present it, but how does that data actually drive the plans at the local level to make changes in their investments, to add different programs and to scale those that we know work?

I want to use a little bit of my time to kind of talk about what might look different in the future as a result of this proposal. I think it's probably the most straightforward way to address some of the excitement, some of the concerns, and some of the critique around the proposal that I know a number of you guys on the panel and your colleagues throughout the Legislature are digging into.

So today, I think it goes without saying we have a hard time tracking the money: Where are MHSA dollars going? What are they spent on? And how much do counties have saved up? Tomorrow, this information will be clear, presented transparently to leaders, to the public, and importantly, to those who stand most to benefit from the services, beneficiaries and their families. Today, we can't really tell what we're getting for those billions of dollars of investment per year through the radically transformed accountability requirements.

In this proposal, we will not only have a sense of where those funds are being spent, but on what and for whom. Further, we'll have this information collected regularly, and we'll be able to tell, well, what actually did those early intervention programs do for young people that we targeted and focused on in those investments? Did they reduce the hospitalizations that we've seen continue to go up and up and up each year?

How many black Californians with serious behavioral health conditions experiencing homelessness did we get into permanent supportive housing? How are we addressing that clear disproportionality in the data? But whether you look at it from a homelessness lens or from a behavioral health lens, today substance use disorder programs and services can only be funded through mental Health Services Act Dollars if they're connected to a co occurring disorder.

Tomorrow, counties will have the opportunity to support those with substance use disorders, even if they don't have it or yet have a co occurring disorder. This means young people who might be exposed to or early in their substance misuse can receive services immediately.

As a father of four, a pediatrician, who's taking care of lots of young people with those early concerns, issues of substance misuse, knowing that these funds could be used to support those young people in their journey of getting support and care early, I think is really important and just makes sense. Today counties certainly invest some of their MHSA funding in housing interventions. Some of this funding is in unique programs. Others are attached to programs like their full service partnership program.

Even in counties who stretch themselves to invest in housing, it's not always an explicit priority. And yes, I use the word service with housing very deliberately. I've heard in the critique that we're shifting money from services to housing. The truth is, if you engage with those practitioners who are working with people with severe behavioral health conditions experiencing homelessness, many of them would say the service that person needs the most is to be housed.

That helps them find stability, that helps stay on the plan and the program to continue to hopefully bend the arc of their life towards stability and community engagement. I know that Dr. Kushal mentioned the data that before this study, we would regularly quote the figure of one third of Californians experiencing homelessness had a serious behavioral health condition.

I think the study's data show that we probably had an underestimate and that the housing instability of those with serious behavioral health conditions in California is even greater than we once thought for FSP, the future is looking different. We today have full service partnership programs of many different varieties. You've seen one county's program. You've seen one county's program. You do not have a statewide approach to full service partnership. Tomorrow, as a part of this proposal, we will have significant standards.

Statewide begin to in many ways require certain components to FSP that don't exist today in collaboration, creating different levels. So people, as Dr. Kushal mentioned, can sort of scale up and down on the needed level of service, including different elements like engagement and outreach, ensuring that some of those important outpatient services that we've also been talking about are built in to those FSP levels.

Look forward to creating a more standard, expected set of practices around FSP, and I will end with the focus on the planning process. So much of what goes into the MHSA planning process today is done county by county in their own important and unique ways. But that planning process doesn't always have the representative voices that I think many of us value, especially from an equity lens at that table.

The planning process being proposed not only focuses on how do we have standard outcomes statewide or locally driven outcomes based on the data, or how do we have a three year plan that builds on the prior three year plan, it invites a whole set of stakeholders to the table to contribute to that plan. And as I hear the fears of this program potentially being cut or that program being cut, nothing in the proposal requires a set of programs to be cut.

But to have the driver of what a local county's behavioral health services plan looks like, how it engages and interacts with the other parts of their behavioral health system, include the voices of so many groups that don't always have that sort of access. And if we believe in the concept that equity is empowering groups who don't have power, having a seat at that table and that voice, I think, is a manifestation of that equity principle that I know so many of us believe and support.

So I also want to just say that a lot has changed in 20 years, that if we want to see the efforts of many of the important programs in California that have been introduced that are either already implemented or in flight, we can't expect to just do things the same way today. This proposal that you are considering helping us improve through amendments and other considerations, I think really has a chance to help guide it isn't the only thing that matters in behavioral health.

MHSA often has represented about one in three, maybe one in $4 in our public behavioral health system. But it is the grout, as I like to call it. It is the piece that allows us to braid and blend so many other programs together. So recognizing the new opportunities across California to advance our leverage of Medicaid, our blending abrading of other health and non health dollars.

I think the time is now to consider these changes, to consider how we can create the kind of flexibility that counties have been asking the kind of accountability that Californians have been asking for in our pursuit of a system that I think we can all be proud of. One that not only is reliable, who need the service today, but has the capacity to meet the need of so many tomorrow. So with that, I'll wrap up and just thank you for your time.

Thank you, Dr. Ghaly. We have a couple of Members I. Know who have questions. I do as well, but I'll save mine towards the end. I think Dr. Arambula was first.

Thank you. First, if I may. I want to appreciate the Administration for the mental health movement that we're in the midst of, whether or not it's the Mental Health Student Services Act, the Children's and Youth Behavioral Health Initiative, the B Chip, the behavioral health infrastructure dollars that we're making, or many of the nine, eight, eight, and school demonstration projects. This Administration has done more for mental health than any previous Administration.

And so before I begin my comments, I just want to acknowledge the efforts that this Administration has done, the historic attention that you've paid to the crisis that's before us. But we spoke about equity and we know that that which is not measured cannot be improved. And currently we have many data gaps within the DCR, the data collection reporting, as reported by MHSOAC, a third of all the data that's reported doesn't have any type of demographic data on race.

And it makes it awfully difficult for us to make improvements if we're not getting the important information back. And so I'm hoping you can speak to the Comprehensive Behavioral Health Data Systems project and the opportunities for us within that project to better collect data, as well as if there are any outcome measures that we're looking towards to include into that project to ensure that we are collecting all of the appropriate information back.

And if you want examples of those outcome measures, happy to provide what the MHSOAC has. But just want to make sure this project has the capability to collect the information that we require.

First, appreciate the acknowledgement of the tremendous effort by the Administration and the Legislature in partnership, hearing the voices of so many Californians who, frankly, are demanding us to do something different than we have done today. And I also appreciate the question about data and equity in that data. There have been in the plan that is being required, it is really meant to be data driven. But to your point, if they don't have the data, what is driving the plan?

So there are components here that require us to build out the nuanced data broken down by race and ethnicity. We have heard from stakeholders very recently about the need to do that in a finer, more exacting way and appreciate the opportunity to create that precision within the law that requires counties to look at and collect data based on race and ethnicity, sexual orientation, and gender identity. Language, whether it's available in a wide services, are available in a wide array of languages.

I think part of what we propose here is also to set some statewide outcome measures. We also expect and hope that counties will, in their individual way, come up with some outcome measures as well that are focused on equity and driven by data. But the point I think that you make that is not just most compelling but most urgent is we need to up our game, if you will, on the ability to collect that data.

Counties don't necessarily have the infrastructure and the ability to do it today, and frankly speaking, the state doesn't have the infrastructure to digest that data even if we were to receive it. So part of what is the underbelly of a lot of this proposal is a commitment to building the infrastructure at the local level and at the state level to do exactly that. Because today, frankly, we don't have the ability to do some of it in the way that I think is expected. And embedded in this proposal is that capability. For sure.

I appreciate that and believe it's important for us to disaggregate much of that data. I oftentimes have to remind people Latinos are not monolithic and oftentimes include many indigenous tribes that speak different languages, and our ability to disaggregate that data allows us to better then serve our community. I'll follow up on data if I can.

When we look at full service partnerships from 2016 to 2021, we see a significant portion of those new full service partnerships are coming from both children and transitional age youth, 45% for children and 22% for transitional age youth. With that knowledge of FSPs, should we be looking at a certain set aside, a percentage for FSPs to be spent on children and transitional age youth? Should we be looking at a set aside within housing overall that we're looking at for children and transitional age youth?

Should we be looking at a percentage overall of BHSA to focus our attention on getting upstream and providing resources to those who need the resiliency? I'm speaking to you as a pediatrician and father, but know that it's important for us as a system to be making the investments where they count the most as well.

Yeah. First off, I want to highlight that through the last many weeks and months, frankly, and deep engagement with many of you, your teams, and various stakeholders across the state, really focusing those early intervention and prevention dollars that are set aside in the act to be set aside for those 25 and younger. It makes so much sense to do that.

It is the history of what so many folks have fought for in the evolution over the last 20 years of the MHSA reform to maintain that and not just allow it to be in regulation, but to put it in the law has been important as it relates to full service partnerships and housing. Specifically, there are needs across the state for so many groups. We often talk about the needs of young people, and especially those LGBTQ youth. Tay youth.

Youth transitioning out of systems well accounted for the housing needs and requiring that in the planning process, both for FSP and housing, that we have an acknowledgement of that disproportionality, that extra important need and how counties address it, we think is important. Similarly, on the other end of the age spectrum, we know and Dr. Kushell's study demonstrates that the fastest growing group of people experiencing homelessness are older Californians over the age of 50.

How do we pay attention to that clear demographic and its intersection with behavioral health? So the question isn't one just about set asides and approaches to making sure that a minimum dollar amount goes to a specific group. But I think this focus on how do we get the nuanced data, the disaggregated data to be used at the local level to drive the plan and paying attention clearly with poignant questions, expectations in that planning process to consider some of the things others as well.

But some of the things that you just mentioned we believe is an important both improvement and strengthening of the proposal, while we also allow for the unique needs county by county to drive without a prescribed set aside here or there for the many different entities or groups that need it.

I will just say that the ability to use both CalAIM, BH connect so many of the other investments as well as the Behavioral Health Services Act funding to help solve the housing and service needs of young people who have serious behavioral health, substance use disorder and mental health conditions is real. And it's an opportunity we expect counties to build in deeply in their plans.

Earlier you said that we could use these funds to address children and transitional age youth. But I'm really trying to ask, should we mandate and make it an explicit priority hearing from the stakeholders that have participated this year with BHSA? Shouldn't we bake that into the plan and prior to allowing that community process to begin?

Or are there consequences to us doing that is what I'm trying to make sure, because otherwise my concern is we're not going to be prioritizing with the intentionality that's needed to focus on this population and their needs as well.

I think one of the drivers we want to make sure we preserve here is the level of flexibility that is really called for and needed county by county. That said, I'm sensitive and acutely aware of your point that flexibility means that you may decide not to invest in one really important area or group or program because for whatever reason in that county it wasn't focused on.

I think our solution to that is building in really poignant and required questions or components of the plan that say how did you address this disproportionality in housing services for young people or older Californians? So I think creating a table where specific areas are clearly addressed, responded to in the plan submitted to the state for how these dollars are used safeguard around overlooking some of those key things while maintaining that flexibility. So appreciate this tension.

Obviously have struggled through it ourselves quite a bit and feel that the solution that I just shared is one that helps us ensure that we're not allowing us to blindly overlook a really important group that has historic disproportionality while creating the flexibility that counties use.

Final question if I can. You spoke about the integrated plan for Behavioral Health Services and outcomes, the new stakeholder engagement that's coming forward. Are there opportunities within that to build in those outcomes that you were just speaking about? Could we require how much they spent on children and youth as an example of their funding at the county level as one of the requirements of the plan?

Could we look towards what MHSOAC has said, the frequency and location of services, increased housing, reduced justice involvement and increased social connectedness as metrics for us to again bake in to that stakeholder process to ensure that we're focused on the right goals as a system?

Short answer is absolutely the intent of creating statewide measures and outcome measures are to do exactly that. You can simply say how much of this plan was spent on zero to 25 or zero to five? How much on Californians over the age of 50? How did this change the data over a three year period around people with behavioral health conditions in county correctional institutions? I mean we have the ability to craft exactly what those are with stakeholder input.

So we have some statewideness to this and it's not just locally driven but there's also that opportunity at the local level to create those important local outcomes that we will also expect some accountability around.

Thank you.

Thank you. Next, Dr. Jackson, please.

Thank you very much, Madam Chair, thank you for being here. I want to associate with the remarks of Dr. Arambula. Obviously, the data is clear that youth are in a mental health crisis throughout this nation. And I think my first question is through this proposal, especially when we look at set asides, does this proposal set aside more money or less money for youth?

So it's a really important question and one frankly, it's the rubber meets the road question for young people. If you look at the prevention and early intervention dollars in today's current MHSA allocation, it is by our account, the dollars in the prevention bucket, and the early intervention bucket, when brought together, is roughly $700 million dedicated to those efforts for youth, wherein in the prior model, it was closer to 630,000,000.

So in total, with the statewide prevention proposal and 51% of the Behavioral Health Services and Supports category of funding at the local level being dedicated to early intervention, and half of that focused on people under the age of 25, when you bring that together, we see it as a higher level of investment for young people in those two areas.

I don't want to conflate that in any way with proposed set asides for young people or other groups within either the housing intervention bucket, which is brand new, as you know, or the full service partnership category of funding. But if you strictly look at where in today's regulation there's a focus on young people, the investment will be greater. Not just because of increased dollar availability, but when you look at the percentages on any amount of dollars in any year, we would see more invested in those two areas for young people than we do today.

Thank you for that. Obviously, we know that our Native American brothers and sisters top the charts when it comes to mental health, substance use, those issues, and then second are African Americans. And when we talk about in terms of making sure that this is anchored in equity and not to mention the LGBTQ community as well, we know that LGBTQ students were nearly four times as likely as their peers to attempt suicide. We know that that continues to climb.

What in these proposals really address what we know are the unique needs that, again, if we continue to just do this all of the above universal approach, we'll never get to exactly what we need for our Native American brothers or sisters or African Americans and our LGBTQ communities. What are we specifically doing in this reform to making sure that we do not miss out on the opportunity to ensure that we are meeting those specific needs?

I think a few things are clear and again, referencing the planning process, requiring counties in their planning process to a, include a diverse range of stakeholders, including membership from many of the groups historically overlooked that you mentioned. Secondly, driven by data. If the local data, as the local data bears out some of the disparities that you're referencing, making sure that the county plans address that data and how they're allocating and spending the dollars and on what programs. And third, in the outcomes, we have the ability to make sure statewide outcomes address that disproportionality. The onus is on us at the state level with our partners to create what those outcomes are and then the ability to hold counties and local partners accountable around delivering that.

The second area of opportunity here is the interaction between the early intervention dollars that are focused in large part in a majority part, 51% on young people under the age of 25 making sure that those dollars are interacting with the opportunities with the Children Youth Behavioral Health Initiative and using evidence based programs stipulated or required as part of early intervention programming under BHSA to ensure that they are built into the fee schedule and that they have an ongoing funding source through plan and Medicaid payments in the future to ensure that not only are they there for a three year planning cycle, but they have an opportunity to continue on addressing our ability to meet the needs of those often overlooked or invisible groups in a school setting where they often interact and have relationships.

So we think that there's a number of places where this proposal not just underscores our focus on some of that disproportionality that you're mentioning, but also allows the BHSA dollars to work well with other programs that we already have existing in California.

And if I just may add, we've really have uplifted the community defined practices as models that we want to see kind of scale in the state. So in full service partnerships, really identifying that community defined practices as well as evidence based practices are used as part of the model today. FSPs, that space generally isn't really kind of filled with community defined practices.

So providing really the opportunity to, what are the kind of the interventions that might meet a particular population's needs and kind of ways of engagement, including that there. And then also over the last couple of days and weeks we've been meeting with various consumer advocates and wanting to actually strengthen some of our language a little bit more with regard to community defined practices. So future amendments on that will be forthcoming.

I'm excited to hear. I was actually a, before I came here to the Legislature, I was actually an administrator of a PEI program derived from community best practices that actually yields statistically significant outcomes. I know there's issues in that not all programs originating might be able to yield statistically significant programs. I understand that concern as well and we need to do something about that. But I would also hope that we continue to double down to making sure that even those statistically significant programs are done in a way that is scalable and replicable, right. Instead of these gems but no one else can replicate it because it's so expensive, it's so complicated, and those things as well.

So I hope that we can continue to strengthen the language to ensure that when we do do these things that we can making sure that we can actually make this something that can be done statewide or depending on the populations of each region. My last question is, well, two questions. The first one was in the original version, it limited the Legislature's ability to make revisions to it that weren't significant, to actually have to go to voters for revisions. Was that provision taken out in the last amendments?

So the way that the language is structured today, so I'm going to get a little technical for a second. Section 8118 of MHSA, which is really kind of the statute that governs or the language that governs the Mental Health Services Act today, and that states essentially changes in furtherance of the act. It's a two thirds vote, minor technical changes 50%, and then substantive changes need to go back to the voters. That law remains in effect as part of this.

And so what the new language is, is really any changes kind of of the new sections that are added as part of BHSA would require a majority vote of the Legislature and all other changes would go through kind of that legal assessment of is the act in furtherance, then it requires a two thirds. If it's technical, it's a 50 majority vote, and then if it's substantive, it goes back to the voter. So it is a legal assessment based on what the change might be every time it's proposed to be modified.

Thank you. And my last question is why do we find it necessary to weaken the Mental Health Services Oversight and Accountability Commission?

So I think in our view, we are not weakening that authority or that ability. We actually in maintaining its independence and its ability to work closely with the department, the agency, and other stakeholders on things like technical assistance, data analysis and reports, oversight, if you will, of counties and frankly of ourselves, that that strength of the OAC can be deepened and furthered.

And in fact, I think through the last many weeks and months of conversation, the ability for a renewed relationship, not one that says let's do everything the same and together, but one that is done in consultation and collaboration between the Department and the OAC to really further our ability, maybe to row in the same direction, I think is the underbelly of where we are today with the OAC.

I know that there's in ongoing conversations on how to make sure that that's manifest in the language and the law, but even more than before, I would say the ability of us to row in the same direction and push the system towards improvement is stronger in this proposal than it has historically been in actual where the rubber meets the road in our work together. So we believe that we're in a place of a strengthened relationship and ability to move forward and that the OAC has a great deal of ability to influence where this entire system is going.

I would encourage us to continue to work on this language. Obviously, reading from the LAO, it says relative to its current role and authority, the proposal still shifts the majority of the commission's current oversight, regulatory, and programmatic authority over MHSA funding to DHCS. So to me that's quite a weakening, I mean, we may call it different, whatever, but obviously there is some significant shifts that are happening.

And so I would encourage us to strengthen that language and ensure that because there are some of us who actually enjoy the type of autonomy that the oversight has in terms of being able to have more frank and honest conversations that we can't have with other folks. And so still very concerned about this and I hope we can continue to make progress on this. Thank you very much.

Thank you. Next, Assembly Member Waldron.

Thank you. I will try to be very brief. Thank you, Dr. Ghaly and your team for being here. Very important issue. I first wanted to add a little bipartisan support for the work that you've all been doing. It's really critical. As you know, I've been eleven years in the Legislature, really focusing on mental health and substance use, especially with the justice involved, population and getting more access into rural communities as well.

We do appreciate what's been done, especially with the innovative approaches that are kind of more relative to what we're experiencing here in our state. Dr. Arambula did take a very important question, which I think is on all of our minds, so I won't elaborate on that, as you've already addressed it pretty extensively, about prioritizing the funding and the resources for the youth, which is a big part of prevention and will save us money in the long run if we can really get a handle on it.

So I have just two quick questions regarding the proposal. How would this complement the initiative that the Legislature supported, the Behavioral Health Bridge Housing Program to provide housing support to homeless individuals with behavioral health conditions? How would this all work together?

Well, Behavioral Health Bridge Housing is funding going into counties now, and it is really meant to be a bridge to another solution for ongoing funding to focus on the housing needs of those with serious behavioral health conditions. So in some ways, the bridge to what? The bridge to this. So they work together. They are meant to be sort of in a continuous sense, supporting those housing interventions that are proposed in this legislation.

Yeah, because we need the wraparound services, we need those things and have them accessible and available. But then I have to go to my heart of things, the criminal justice system, the cycle of recidivism that we're getting. People are incarcerated that really need to be in treatment. Excited about the approval from CMS to allow incarcerated people to segue into the MediCal system prior to release. And that will be hopefully a very successful program once we figure out how to get it all working.

How can we be sure that they don't fall through the cracks as they transition and go on? Some of the biggest problems we have is that cycle of going back onto substance use once folks are out and the high rate of overdose once they're out. How can we have that, once they're in the program, that we can be accountable for them once they're out?

Well, I think the easy answer, there is no easy answer to this, right? But the easy answer is to use all the time while people are incarcerated to make a solid, thoughtful, sort of believable plan for an individual when they come out. Ensure, talk about warm handoffs and referrals that are meaningful and real to make sure that that happens, and then to make sure that resources like those available through the Behavioral Services Act proposal, the Medicaid Services under CalAIM, things that are happening because of the Behavioral Health Connect proposal and so many other elements that I've referenced today, that they're actually blended and braided together in that person centered way.

That people have a reliable point of contact, case manager, they have a place to go and sleep, they have a reliable place to get their care and services. And that the basic needs of individuals don't fall through the cracks. And so those opportunities across California are more available now than they were before and we have to deliver on them.

Yes. And I agree we can see a big dent in the problem. I think if we could get a handle on the folks that are in the criminal justice system because then their children get into the cycle and it just continues that. So thank you very much.

I'll just add one last thing because it highlights the need around workforce. We talked about it on the prior panel. The BHSA proposal for consideration dedicates 3% of dollars to ongoing behavioral health workforce needs, building up both the cultural competence, just the bread and butter positions that we need both for substance use disorders and behavioral mental health needs. That it allows us to really build the team of folks that are going to make what we just talked about real and available to more people in California. Because today, without the workforce investments, we just have really interesting and exciting plans that frankly won't deliver on what we all hope they will become because you don't have the people to do the work.

Thank you. Next we'll have Ms. Quirk-Silva. Or do you want me to skip? I think Dr. Wood was next, actually. And then we'll go to Quirk-Silva.

Okay, I wasn't following the order

I'm just taking the lists. It's a long list too.

Okay. First of all, thank you very much, Dr. Ghaly, for being here with us this morning. Just a couple of quick things. You and I, we've been talking a little bit about volatility and the funding piece of this. And I know that's an area we're going to continue to work on so that won't necessarily be completely reflected in the bill that we'll hear later today. Just some thoughts on that if you have anything quick.

Yeah, first, I want to really appreciate both our county partners, the LAO, you, Dr. Wood. Others in the Legislature have raised this as a really critical issue. We've recognized it for a while. We've all talked about prudent reserve for years. And how does that make sense in the broader goal of trying to make sure as many of these dollars are activated for services here and now because so many people have need and there are gaps.

But, with that sort of principle in mind, recognizing the need to create some real reliability, the fund source is clearly one that's volatile. It goes up, it's go down. In my short time in this role, I've seen enormous swings in the amount of dollars available in MHSA in one year versus another. And it is hard to plan in a reliable way.

So what I will say is there's a commitment to continue to work with the Legislature, our county partners, key departments within the Administration to figure out what's the right path around addressing those reserve needs while ensuring that we're maximizing opportunities to deliver on services today. So what that exactly looks like? I think there's a few proposals and ideas that many of us are kicking around and thinking through and the expectation is before this bill is final and considered, that there is a way to address that volatility in a way that sets California up for success.

And then the final question is around, and I'm struggling to figure out how to phrase this, but I think you'll get the gist of what I'm after here. But we have a lot of great community partners and organizations and counties and everything doing amazing things in communities. From my perspective, it often feels like everybody's operating in silos. I think people hate that phrase, but that's how I see it.

And so my question is, is there going to be, and if there is, who or what entity is kind of an overarching entity that's going to look at this and be able to over time see are we being successful, what are we doing? Because the public will judge us by all of this. And what they're going to see is are homeless people being housed? Are we seeing the diminishing of that population on the streets and are people getting the services that they need to be successful?

So is there, I hate to use this word, is there going to be some sort of a Czar or somebody or anybody that's kind of looking at the big picture that's the face of this, is that you? Is that Director Baass? Because I think we're kind of looking to see, is this all being coordinated, how it's being coordinated and what's being successful?

Well, first I want to acknowledge again the Legislature for pushing, and Dr. Wood, you in particular, for sort of some interim reports, some real focus on making sure that the directionality is real, that we're seeing the fruits of this labor today manifest in how the plans are coming together, county by county, what those outcomes are, so that we don't just turn our back and expect that everything is going to turn out the way we hope today.

That we get that opportunity to make that refinement and change in approach, as Director Baass mentioned, the ability and the furtherance of the act to do what this body is asking us to do. So that's one thing. The second piece is really in collecting those county by county plans, being able with a lot more precision and completeness than we do today, to be able to pull some of those model programs out, to say, hey, look, this is something that this county has done for one, two, three planning cycles. It's been effective.

It is what they attribute to changing this sort of county based outcome that needs to be considered by other counties and to sort of, say, the shared responsibility between the OAC and DHCS to continue to call through those, look through those plans, call those gems, or even things that maybe aren't turning out the way that we would expect they are and share that information in their analysis.

So I think with this robust planning tool that is being proposed here in this change, we have great opportunity to do exactly what you said. I don't want to anoint myself or assign myself that role, but I would say that it is going to be a work between the Department, DHCS, our agency at HHS, and our partnership with the OAC to look at that.

Just to quickly supplement the secretary's point, the housing component. My boss is Secretary of the State Consumer Service and Housing Agency, along with Secretary Ghaly, chaired the California Energy Council on Homelessness. And we speak to a lot of the efforts underway with our partners at Health and Human Services, county regional planning, where we've really complemented that on the housing space. It's always the additive efforts on housing and healthcare because that's really how you get viable long term solutions ultimately and pair these investments together in strategic fashions.

Thank you. And we'll go to Ms. Aguiar-Curry and then Ms. Quirk-Silva.

Great, thank you. And thank you very much for your presentations. Everyone that's here appreciate that. Dr. Ghaly, the Administration doesn't support legislation without a budget item approved to fund it. Doesn't this bill depend upon the funding from an as yet unapproved bond?

Well, just to be clear, the bond and the Behavioral Health Services Act obviously have a lot of interaction and build together. The bond, just in the quick summary, I think focuses on building some of these service settings, treatment settings that we're lacking in California and we don't have the ability to, we often talk about this continuum to move people through.

And the Mental Health Services Act changes into the Behavioral Health Services Act, I think, provide a lot of, we've heard the word wraparound or support services or clinical services that are required to do more than just put a roof over somebody's head, but to make it a meaningful treatment program so they absolutely work together. And I don't want to dismiss that in any way.

But the changes that we're talking about on the Behavioral Health Services Act, Proposal 326, are really focused on changing how those existing dollars that have been voter approved nearly 20 years ago under Mental Health Services Act get deployed, in some ways redeployed in the environment that is more modern and paying attention to many of the things that we have today. So, of course, the bond and building those brick and mortar settings that are being proposed are critical to this. But the comments and discussion we've had today do in some ways stand apart from what that bond is.

Thank you very much. This proposal creates a lot of new mandatory local integrated planning efforts. And small counties like the ones that I represent in the district have limited mental health funding and still have to do the job. How does the state plan on providing substantial technical assistance and support for my counties?

So, two things to say. First, to start with your focus on technical assistance, I think we build our capacity, meaning not just how do we do it, but how many people do we have available to do it. Director Baass, our OAC partners, making sure that we deploy the funds we have available to execute on this, to build those TA teams and to be available county by county.

We've already had some really important conversations with some bigger, some smaller counties about some of the challenges and needs that they might have as a result of these changes. And frankly, to use a word that I don't often get to use here, excited about some of those changes that could come. Secondly, for small counties in particular, the focus of what was originally proposed as a 2% allowance of local administrative dollars to focus on building up those planning efforts was increased for smaller counties to make sure, to address exactly the point you're raising, that there are sufficient dollars. Hopefully sufficient, but more than currently proposed to do all of that important planning work.

Well, as you can imagine, I've had a lot of conversations coming through, so I have a few more regarding our smaller counties. Given the concerns raised by counties and other stakeholders about the loss of local funds to support mental health services, how does the Administration propose to ensure that Californians with severe mental illness do not lose their core services. And if I'm not mistaken, as much as we support CalAIM, it is not a replacement for mental health outpatient crisis and peer services. This must be my local, my counties.

Well, it's your county and many other counties. And this has frankly been one of the most important pieces that we're all talking through grappling with the idea that outpatient services would be sacrificed because of the changes that are being proposed here is no one's intent. Let me just state that clearly, that in some of those county by county conversations, we have discovered opportunities to support outpatient services, maybe in ways that today aren't often deployed. We've talked a lot about how do we blend and braid funding.

There's opportunities that have been missed in some counties that other counties are taking advantage of, opportunities to leverage Medicaid even more, to draw in some of the other payers for these services to make sure that the funds are augmented. And then importantly, in recognition of exactly this point, there is an amendment that is today in print that wasn't there in the original proposal that creates additional county flexibility.

So wherein the buckets were fairly prescribed, you had to go into them with those exact percentages in our first planning process. So in the years 2026 through 2029, any county can move 7% out of any one bucket. And not 7% of that bucket, but 7% of the total local dollars from one bucket to another, up to a total of 14%.

So if there's a concern in a county that a set of services, we just can't figure it out with this new world order, they can move dollars in to support that. In the second planning process, that's reduced just a little bit down to 6% out of any one bucket with a total up to 12%. And then moving forward after that second planning period, having 5% of the dollars movable out of any one bucket up to a total of ten, creates some ongoing flexibility county by county.

So our direction, our compass is still the same, but that we create some recognition that not every county is going to be able to do exactly the same thing and they'll need some flexibility. This is flexibility that frankly hasn't been in MHSA ever. And having this opportunity, I think, is a really important feature of the proposal.

I love to hear about flexibility because that's one of the things that they were obviously quite concerned about. So I'll be anxious, I'll take some time and look at that amendment. You know, I go to the counties and I've met with a lot of my mental health organizations and they're doing such a great job, many of them, because they've had to think outside of the box for so many years. So now they're concerned about the disruption that might bring them. So I appreciate you being here today, appreciate your answers, and let's see what we can do. We got to make this a change. So thank you very much.

Thank you.

Thank you. Ms. Sharon Quirk-Silva.

Thank you, Dr. Mark Ghaly. I'm pleased to hear many of the proposals that I agree with. For example, having standardized measurements throughout the state. We know county by county there's a lot of uniqueness, but we also know, for example, in our public schools, we have standardized, if you want to say assessments, to make sure that throughout the state we have the same goals.

One of the statements that I have is when we look at our major institutions that we as a state government are responsible for, whether it's public education, prisons, probation, health care, even now, housing, we continue to see inequities, inequities as you mentioned, of who is not only getting these services, and many times in all of those institutions, we see very poor outcomes for our communities of color, including Native American, Black, Latino, and our LGBTQ plus communities.

I appreciate the idea that you want to bring together stakeholders to now make sure their voices are heard when these decisions are made. It still remains the question that some of these committees or boards, in fact, depending on the county. I have Orange County and now parts of Los Angeles, very different governing boards. And when I look at who represents, for example, Orange County, the largest provider is CalOptima.

And I look at, in fact, that board, to me, it would be very difficult to see how these communities may be we and how do people become Board members? So all of that, who gets appointed? Typically, it has been done by supervisors. Depending on your supervisors, you may have a very diverse board or you may not. And now that I represent two counties, Los Angeles and Orange County, pretty much night and day as far as what type of programs are being executed.

So my question is, how can we ensure that there will be some equitable representation? That's question one. And then the second is everything that we do in these institutions, whether again, it's education, whether it's people coming out of our prison systems, whether it's access to health care, the key ingredient, including people living on the streets in encampments, is about access.

It's about how do we get somebody who hasn't always had experience with traditional government institutions. Whether it's going to the school site, whether it's going to a probation officer, whether it's going into the healthcare, to get questions answered, to actually get the plan. An example is my in-laws speak Spanish. My husband many times needs to go with them to get a plan. And sometimes, even with him there, there's sometimes just not the best outcome.

So then imagine living on the street, what type of interaction there. Imagine, as you know, even public engagement people, if they don't speak the language. So the question on access is, are we looking at who we are building a teamwork and how they can engage with people that are in very vulnerable communities. So, two questions, thank you.

Sure. I'll try to answer them both. And first say the board differences between Orange County and LA, notwithstanding the strong leadership in both behavioral health departments in those counties, is exciting. You have really tremendous leaders who are pushing the envelope on a number of different programs and areas and I think really doing some very important and interesting work that should help guide this state. So just a shout out to the work that they do day in and day out.

In terms of sort of your questions, I would say, first off, the proposed changes expect something very different. Expect counties in their planning process to include groups that traditionally maybe they were there, maybe they weren't there. And I think in our ability to consume those plans and really take a look at who's at the table in these planning processes, to make those comments, in some ways, we need to have higher expectations and different expectations, but we also have to inspect what we're getting in more detail.

And part of this entire proposal really pushes us at the state level to invest some of our state administrative dollars in supporting our department, agency, the OAC, others, to be able to look at these critically, so that when we hear the story that, hey, this county was really good at choosing strong representatives of some of these often overlooked issues to be at the table, that we can actually verify that and point to that as the reason why one program or another continues to get funded.

This is not an easy thing to do. We still want a lot of county autonomy. So those local, unique features are manifest in their plan. But I think setting a floor of expectations is exactly what we're doing in this proposal. And building the team at the state in many different areas to be able to inspect that those expectations are met is the approach that we have now.

You're good. Okay, great. We'll go to Mr. Fong now.

Thank you, Madam Chair. Thank you, Dr. Ghaly and your team for your hard work. Appreciate the complexity of this issue. Wanted to kind of build upon some of the questions asked by my colleagues in Northern California and specifically the concerns of the counties because I know you've worked very extensively with the issue. I've seen, and I referenced LAOs analysis, which you've read, which says this proposal, amongst many things, would require counties to spend more on certain programs and less on others.

And I've heard from my behavioral health directors that this Bill does require new services without the potential of additional funding. And my colleagues and I who serve on the budget committee certainly understand the budget constraints there. So the concern of diverting funds from really important things that are already occurring and trying to manage the tension that exists of unpredictable sources of funding, maintaining programs, and then adding new requirements.

How do you respond, I guess, to the concerns of the unintentional potential of reducing the level of funding that's currently spent on core mental health services, particularly outpatient and crisis and recovery services?

Yeah. So let me start by just re-acknowledging the volatility issue, which is real and one that we expect to address, which I think will bring a level of consistency and security at the counties to be able to look at some of these important pieces. Heard that loud and clear. See this as an opportunity to address something that has been a long-standing issue and frankly has probably mocked up our ability to understand differences between county approaches.

So wanted to say that again as a really important part that isn't in today's amendments but as something we're committed to before this Bill is fully considered to having in place. So that's number one.

On that note, though, can you give us some concepts that you're bantering about in terms of how to address that?

Sure. I can say there's obviously the LAO has presented a few ideas. We've certainly looked at well, how do you look at historic spending over the last period of time? Looking at the last three years to inform the next three years? Looking at how you consider waiting certain years? Potentially, but also pushing forward a concept that maybe we need to take our time with a number of the right partners at the table to figure out exactly what the replacement is of the current prudent reserve approach.

So that we do something with input from counties with the support of the Department of Finance that obviously has to think through this on a year to year basis to make sure that those pieces are there. Again, working closely with Members of this committee and making sure that we get a broad range of ideas in place. I think the certainty on what it is is less today, but the certainty that there will be something is pretty firm well, I don't want to interrupt you, but I know that was only a portion of your question, not more important, but the equally important piece was, well, okay, we have certainty now.

We have a way to plan that doesn't sort of have the big ups and downs that I know as somebody who ran county programs for a while, would be very difficult and frankly frustrating to meet the needs around. We also know that certain things over the past 20 years are in place today that weren't in place before. And an opportunity to leverage certain programs, funding that we can get through the federal government, through programs that Director Boss's Department really oversees and puts forward.

That there's lots of opportunity, for example, to invite other funders into the mix around outpatient services, to ensure that we're leveraging all of the different opportunities within outpatient services to draw down funding, to make sure that things that maybe we spent 100% MHSA funding in the past that in the future we might have an approach that allows us to bring other resources.

So without diminishing the potential and maybe even scaling up some of those really important services, we think we can sort of broaden the pot if you will, that's available to fund all of these services. I know that as we go county to county and have these conversations, there'll be lots of opportunities uncovered discovered that we have some time to begin to think about how to implement.

If I may just provide a specific example to just kind of underscore what Secretary Ghaly mentioned in conversations with counties, particularly about outpatient, really kind of highlighting that come January 1, 2024, we have undocumented expansion for medical. And so some of the services that they may be funding today with 100% MHSA dollars for outpatient services, for example, there will be new funding sources for those services, so thereby freeing up some of those mental health services dollars that can be used again for kind of different purposes.

So there's some specific examples as we talk to counties and try to unpack how they're using their dollars today and what the potential changes in the future might mean for how they plan. For the future.

Mean to follow up on my colleague, Assembly Aguiar-Curry, I think that the challenge is, as you indicated, Dr. Baass, is that there are multiple counties with multiple programs that blend different funds. As Dr. Ghaly said, a lot of programs use braided funds, they use medical resources as the primary funding, and then MHSA patches wherever it needs to be. And acknowledging the need for housing and acknowledging the need for mental health services and, of course, treating substance use treatment services.

All of those things encompass into this proposal creates a lot of resources and needs and capacity issues within counties. And I think that the concern that I'm hearing is that how do you provide counties with especially rural counties with the certainty as you add in more responsibility and I look forward to the amendments. I will ask to follow up specifically in terms of the key elements of this proposal are bonds and asking the voters to decide with uncertainty in the budget, wearing my other hat, what happens in that dynamic if, let's say, the bond doesn't pass or something doesn't occur? What happens in this situation or in that situation?

I think, first off, as I mentioned, what we're considering under SB 326 is really reform. We like to say modernization of the Mental Health Services Act of today and the hope and hope expectation that the bond will pass and that we will have the resources to build up many of the settings that we've described in that bond language is there.

But notwithstanding that, these changes that can take place within the Behavioral Health Services Act do stand on their own and can be considered by themselves with the funding that we get year over year because of Prop 63 and 19 and a half nearly 20 years ago.

What the voters pass on that going back to something similar, but tied together in terms of the buckets. Or do you envision counties having some flexibility, say if they wanted to use some of the let's say there's no housing capacity at that moment that they can shift some of those funds to other services? Or are those buckets hard and rigid in terms of the percentages?

Historically they have been hard and rigid. Proposed amendment over the last couple of weeks is to provide some flexibility that in the first planning cycle moving up to 7% of the total funds at the local level out of one bucket into another for a total of 14% across all the buckets in any one year. So for example, you could move 7% of your housing intervention dollars, 7% of your FSP dollars into behavioral health services and supports because there's a clear glaring need. And despite efforts to figure out how to blend and braid differently, there's still a gap and you need a little more transition time that that is allowable based on the amendments that have been put forward.

Thank you very much. And I think to reiterate what Chair Wood has said, I think there's a lot of moving parts. You've got CalAIM, you've got Care Corps, you've got this, you've got a potential bond and the counties are, I think, just trying to absorb all of these changes and trying to mesh them all together. And I think that coordination is something that's still out there. It's still questionable, and I think that this layering on top of it creates a little bit of unease.

And I think the potential, the impact to these individuals who really need services if they're now in a program and that funding is now unsustainable or has to be changed, we're creating even more uncertainty for a lot of the most vulnerable populations. So thank you very much Dr. Ghaly.

Thank you. Next we'll have Dr. Weber, then Mr. Rodriguez, and then I believe myself.

Good morning, Dr. Ghaly and panel. Thank you all so much for presenting and coming here today and taking all of our questions. I think you're going to get a question from everyone on this panel so that just kind of demonstrates the importance of this. I first want to kind of go back to what Assemblymember Jackson had said before about our pediatric population and for me specifically the issue around prevention.

And you're a pediatrician, a physician, you understand the importance of prevention, and so I've had some children hospitals and other children's services speak to me about the shift from prevention into early intervention, which to me means something has already happened, we haven't prevented it. Something has happened and now we're jumping in early to treat it. And so in our analysis, it says there's concerns that this Bill will result in drastic ongoing reductions in funding for prevention focused programs.

And I know that currently under the MHSA, there are projects that could Fund locally and culturally responsive programs like the Sweet Potato Program and the West Fresno Family Resource Center, which specifically is used to prevent or reduce school dropout, gang intervention, substance use initiation for African American youth, decreasing homelessness, mental health issues along the line. So within this proposal, how would these kind of prevention-focused programs be funded?

So I think really important question that we have been spending quite a bit of time on, specifically the Sweet Potato Project and others named projects like It Director, Baass, and people on my team myself have been digging into, in good conversation, I think, a couple of things to say. First, the way that some of the programs have been funded historically in the MHSA buckets isn't the only way to fund them.

Some of these programs could be funded under the Behavioral Health Services and support bucket that is being proposed. And there's nothing in the legislation that says a program like that shouldn't be funded or can't be funded. Secondly, the statewide prevention program allows us the way that the language is written is to focus on, yes, a statewideness, but also some specific programs that might be in one or two or three or four counties that really address some of the unique prevention needs.

I'll also make the distinction between and I appreciate the acknowledgment of my being a pediatrician. I often say pediatrics is the ultimate form of adult preventative medicine because we have a chance to address the whole host of things at a young age that we know more and more today have real impact on not just your health, but your opportunities into adulthood.

So focusing on prevention at a population-based approach and having those dollars be very specific and available for population-based approaches, I think was really important and not just putting in a single bucket. Prevention and early intervention in many people's minds, early intervention is targeting an individual. It's somebody who for a specific set of reasons, has the need for an early intervention that's specific to them or their family.

And so being able to distinguish the two was an important feature of what we're having play out in this proposal. So three things behavioral health services and supports can fund some of these programs in a way that they haven't necessarily been considered for funding. Secondly, we have statewide prevention dollars to really focus on those broad population, maybe school-based programs that target young people at about 50% or a little bit more.

And then in the early intervention category, making sure though, there's person specific interventions that do get in the way of further sequelae and consequences to early signs and symptoms that we can invest directly in those programs. So by our account, we see this as new set of opportunities to address some of those early issues that I think so many people, including me and our team, are concerned about.

Okay, thank you. And there is a lot in this proposal which is very good and very much needed and overdue, I would say. The issue of oversight, accountability, getting data, using evidence-based information to direct how we provide services, understanding that we have to focus on what I talk about a lot, the social determinants of health to really create healthy individuals, whether it's physical health or mental health. And so you have to address things like housing, you have to address things like racism, otherwise we're not going to be able to do what we need to do. And I think that's why we have not done as much as we could do here in the state of California.

The funding issue is a concern for me. So I'm very much looking forward to what the proposals you all are talking about in terms of dealing with not only the ebbs and flows of the funding stream but also to hopefully increase the amount of funding stream in this area. And I think that's where a lot of other people are concerned about. If we had a proposal that increased the amount of funding that we had in addition to putting in housing and other services.

I don't know if you would have as many questions or concerns today, but the fact that right now we're using the same amount of money to try to do more means that potentially our mental health aspects are going to get less. And we cannot afford to do that here in California. We heard at the beginning that we have an increase in the need for mental health services. We don't have enough people in the state accessing what they should have.

Our youth are having to deal with this at rates that we have not seen before. And so for me, that is honestly one of my biggest concerns. Yes, we need to address housing, but do we need to do that at the expense in taking dollars away from our mental health? I don't think so.

In fact, I know we don't, and that's why we need to I'm very interested in what proposals you'll come up with, because right now, the way this is funded, you've got a small proportion of Californians funding this. It's not enough right now. And so we need to figure out how we stabilize it, but also how we get more funds so that we can do all of these amazing things that we need to do in you're proposing in this Bill.

But I do want to ask about and I don't know if there's been a new amendment that changes it, but what is the justification for lowering the county reserves caps, especially when the LAO came out and said you should actually be increasing it, but the proposal actually decreases it?

Yeah, I think coming back to this statement in the exchange with Dr. Wood recognition that we have to get this right, that that security county for counties is really important and that volatility, as you referenced, is hard to manage and frankly, hard to plan around. And so the commitment is to have a solution to that volatility that I don't have today.

But as I said before, this is over, we plan to embed in the legislation to address that. And I'll just acknowledge that stability and the reduced volatility is going to be really important, but it doesn't solve all of the concerns that you raised. And we look forward to working on sort of many of the issues you flagged that we share, not as concerns, but as opportunities to grow with the resources that we have today, the opportunities to use them to serve those in greatest need across California.

Thank you. And finally, I'm very happy to hear about the flexibility that you all have been talking about as far as how dollars are used because certain counties do well, certain counties don't. I come from a county that in the past did not do very well and we've changed our makeup and are kind of changing our course. But every county is different in terms of their needs, in terms of their community members, and some of the programs that they have to offer their specific community members.

And I just want to make sure that as we're going forward, we continue to allow for that flexibility, especially if those programs are showing that they're helping. Now, if they're not, that's a different story. But if they're working and they're providing a vital resource to the members of that particular community, then we should make sure that we are continuing to Fund and allow for that local control. So thank you very much for being here and for taking all of this time to answer our questions.

Our pleasure. Thank you.

Thank you. Dr. Weber. Mr. Rodriguez.

Yeah. Thank you, Secretary Ghaly and all the Members working on the very important issue. And I too, kind of share the same concerns some of my colleagues already talked to regarding the counties and the loss of revenue. Right. One of the counties I represent, county of San Bernardino, tells me that because of this proposal, they look to lose over $70 million in services being provided. So with that said, and I knew you probably already answered it in one way or another, but how does the Administration plan to ensure that our local partners can accomplish what's being requested of them under this proposal to make sure that those services are being provided day in and day out?

Yeah, I think sort of restating a little bit of what we've talked through. But I think there's a real opportunity as we've gone and spoken to counties on an individual basis. Looked, especially Director Baass's team, at where there's opportunities to do the things proposed in the Legislation and the change in 326 while supporting those other efforts that exist today. Making sure that, as Dr. Weber mentioned, that we're supporting those things that are supported by evidence and making sure we're critical about things that maybe don't have the same evidence and making sure that we have those services continue and be available.

There is going to be a lot of support and technical assistance. We have not talked much today or at all today about the reality that a lot of our most important, trusted, community-based providers don't yet have the capacity to leverage Medicaid, to really do all of the intricate administrative tasks, hoops jump through them that are required to leverage those dollars.

And part of the vision and expectation is that some of that capacity is built up, that we look at a way to, in a more reliable and enhanced way, leverage the federal opportunities to draw down funding for some of those existing programs. So it's going to be a lot of technical assistance, a lot of support investing our own state administrative dollars to be able to provide that support, whether through the Department or the OAC moving forward.

Great. Okay, thanks, everyone, for your participation. I'll make just a couple of brief comments, and then I have just really two questions, and then we'll allow you to go off of the hot seat here. So, one, as housing chair, I have been hitting the drumbeat on housing since the second I got here and appreciate the administration's focus on that. And I'm a big supporter of housing first. I think it's a critical piece of the solution.

So thank you for really bringing that up as part of the solution. Having said all that, obviously there's been some really important questions that have been raised. Right? And so I just want to align myself with some of the comments that some of my colleagues have made this sort of concern around robbing Peter to make Paul and thinking through how we can really work through that because we kind of need all of the things to fix the problem.

I'm also a big supporter of continued ongoing funding for housing. I actually have a bond, I'm trying to get $10 billion bond on the ballot next year for housing. In addition to that, we need, I think within the General Fund budget, more funding for housing for a significant period of time, 100 billion dollar investment over ten years. So if anyone wants to work with me on that, I welcome that.

But that is a real issue that we've heard from our counties, the robbing Peter to make Paul. The other issue that's been raised is the volatility. I know within the past five years alone, revenue in any one year has swung between an 88% increase to a 35% decline. And planning for that is very difficult, as you all know. So I appreciate your continued commitment to wanting to figure out how to figure out these tough issues.

Having said all that, some of the questions that I have, one, the Turner Center did a study recently noting that services and operating costs are chronically underfunded. How will the services and operating costs of supportive housing and residential beds that are constructed through the bond be paid in an ongoing way? And really more specifically, is it the intent that those would be funded by MHSA?

Happy to take that question on the housing front. Thank you, assemblymember, for your leadership as a housing chair. And a lot of the work that my agency in tandem with Secretary Ghaly and his team on really braiding this funding sources, whether it's at the state level, but also clear examples of the work we've done with federal and even local resources. And those efforts ultimately, the theme you're going to hear is to really scale our efforts, whether to address homelessness or housing production overall, the sustainability of the permanent supportive housing units, that's absolutely critical.

Just to give you a quick example, the first two rounds of Home Key are flagship program for the state on providing permanent supportive housing at scale, but also making sure those capital dollars that the state invested. We had two projects, veterans housing projects, one in Merced, one in Santa Cruz. Those units that we provided the capital dollars for were also supported by veteran supportive housing vouchers, federal ongoing dollars.

So just to give you a sense, and with the bond partnering with our colleagues over at CalVet, the efforts that we're doing with making sure that these dollars are strategically leveraged and that really expands to the 30% housing intervention component, ultimately with rental subsidies, other supportive services that make these developments really viable.

We have 55-year affordability covenants that we underwrite to we make sure there's a supportive housing plan, specifically locals are involved to make sure that everyone has a shared investment into the success. And that's where you see to the first panel's point, the long-term success rates, making sure folks have that stable supportive housing component that we feel is really viable here and provides best long-term success.

And just to clarify, so then is MHSA going to be the main funder of the ongoing services?

It would be one of many. To be clear, we have other operating subsidies that we typically parish as mentioned, federal vouchers, project-based vouchers vash. It's very common also the permanent local housing allocation HAP funding that we pair. But to the scale and the ongoing nature of Behavioral Health Service Act, the housing interventions provided, that does provide a unique opportunity, especially with a lot of the work the Legislature has done on making those capital investments available to pair to make everything situated together.

And is that going to be explicit in the bond in terms of what the ongoing funding is going to be?

It would be one of several uses ultimately. And to the secretary's point earlier, there's the discretion inherent with their use of those dollars. So it could be depending on the strategic priorities ultimately within that funding source, they could pair it. And we've seen even for a long time MHSA being a funding source that we've seen tied to units.

But it sounds like from my perspective, we're going to need more resources for this, right, for ongoing funding.

Ultimately the more capital, other resources that allows us to scale. So to the preceding point, the ability for us to have these dollars for counties to tie to other state federal investments, that really does help move the lever. But everything is additive ultimately. So remember and you even with constrained budget environment that we have other flagship programs at HCD that we help to oversee, those are other opportunities that are provided with this proposal.

And on the housing piece in particular, I'm ready, willing and able to work with anyone around ongoing funding for housing because it's very critical. So if this opens up that opportunity, would love to walk through that door with you all. The other question I wanted to raise in the previous panel Dr. Kushel raised, she discussed and I want to sort of explore this further with you.

Black folks are overrepresented in the homeless population but may not receive behavioral health services on the same level as white folks because of some of the sort of structural racism that exists within our health care practices. The bond funding for supportive housing is limited to people with behavioral health challenges. Is that too narrow of a definition or could that create some level of unintended inequities that could be exacerbated? And could we think about maybe length of time or something else just to because that data was interesting to me and I want to connect that to this proposal.

Yeah. So I think we need to have a lot of important conversations about how best to do this. I think our intent is to make sure that some of those disparities in either diagnosis or access to treatment and services based on race or ethnicity or any other distinguishing characteristic that we really work hard through the planning process through our data collection to start to see those erode a bit and ensure that the services that are needed on the behavioral health side are actually getting to those who need them the most. I think Dr. Kushel mentioned specifically also substance use disorder services as another area where we have quite a bit of work to do to make sure that disproportionality is erased.

The idea that the permanent supportive housing units supported through the bond are available to people with behavioral health conditions, severe behavioral health conditions is really critical. To make sure that the connection then to kind of address a little bit more your first question those ongoing services that imagine that one of these PSH units is occupied by somebody who has a serious behavioral health condition. The housing itself is not magical in a way, and Dr. Kushal mentioned it. It needs the robust services that are evidence-based, that are done with fidelity to that evidence-based model and making sure that our BHSA funding and the expectations around, for example, full service partnerships support that individual in that unit.

So in many ways, I think we have to address the disproportionality through a number of different access points, if you will, and the plan is going to be critical. But I think having these units attached and set aside for people with serious behavioral health conditions where there is an ongoing funding source in this proposal to not just fund the units themselves through rental subsidies or other measures but also to make sure it's linked to the services that are needed. Give us the best chance to make sure individuals do not fall through the cracks.

Thank you with that. Appreciate your participation today and we are ready to move on to our next panel.

Thank you for all of your time. Appreciate a chance to engage on all these issues.

Great. And so next we will be hearing this is our fourth panel, the housing panel. Lourdes Morales, Principal Fiscal and Policy Analyst, and Ryan Miller, Principal Fiscal and Policy Analyst. Legislative Analyst office Ky Le, Deputy County Executive, Santa Clara County. Chevon Kothari, Deputy County Executive for Social Services, Sacramento County. And Doug Shoemaker, President, Mercy Housing, California. And I also want to note we will be breaking at noon, so if we're not done with this panel, we can pick it back up at 1:30. You may begin.

Good afternoon, chairs and Members. Lourdes Morales, with the Legislative Analyst Office. I've been asked by staff to provide the committee some contextual information about existing state housing and homelessness programs for veterans and others with behavioral health needs. I will also be presenting our assessment of the Governor's Behavioral Health Bond, which is currently moving through the Legislature in the form of AB 531. You should have a copy of the handout before you that I will be using during my testimony. It is also available at the LAO website.

So on the first and second page of the Handout, we briefly summarize the key takeaways from our assessment of the proposed $4.7 billion behavioral health facilities and housing for Veterans Bond. We find that the governor's proposed bond appears broadly reasonable, as it uses an appropriate funding mechanism to address a well-documented need for behavioral health facilities and housings. But the proposal also raises questions for legislative consideration.

Ultimately, we do find that the governor's proposes a limited role for the Legislature in not only designing, but also implementing the bond. And we make a number of recommendations that would ensure that the Legislature would have an active and ongoing role in ensuring the bond success. And so, before I get to the updates on the existing state program, there's a bit of relevant background I wanted to provide, beginning on page three, about public behavioral health services and how they're delivered in the state.

So generally, counties play a major role in funding and delivering public behavioral health services and communities. Sorry. These counties rely on a variety of sort of major, dedicated, and ongoing funding sources to deliver these services, primarily realignment revenue, as well as MHSA funds and federal funds through the medical program. There was a recent study led by the Rand Corporation that estimated a shortage of behavioral health beds in California.

As shown in figure one on page three, the estimated shortage is significant about 7,800 total units and is particularly severe at the community residential level. Turning to page four, although we know housing affordability is not although we know housing affordability is the most significant factor in the state's homelessness crisis, there is a number of individuals experiencing homelessness who also have behavioral health needs. Estimates vary on exactly how many individuals experiencing homelessness also suffer from behavioral health disorders.

We had some data presented on this matter in an earlier panel at this hearing. Here we cite data from the 2022 point in time count from the US. Department of Housing and Urban Development, which notes that 23% of people experiencing homelessness in California suffered from a mental health illness, 21% suffered from chronic substance use disorder. We know that there's likely overlap between these populations, but the degree to which is unknown.

But we also know that sort of individuals who both experience homelessness and have behavioral health needs could particularly benefit from more comprehensive approaches to care that include both housing supports paired with behavioral health services. On the next few pages of the Handout, we provide implementation updates for four key state housing and homelessness programs. I'll start with the discussion of the beach program, the Behavioral Health Continuum Infrastructure Program on page six of the Handout.

The $1.7 billion in one-time funding provided for this program makes grants available to develop new behavioral health treatment facilities. To date, five of the six rounds of BHCIP funding, totaling $1.6 billion has been awarded. Round One really focused on funding to create and expand 109 mobile crisis teams. Round Two provided planning grants to 50 tribes and county grantees, and rounds three through five made 129 awards that are expected to add 2,500 breads across various facility types.

Turning to Homekey on page seven and eight of your handout, the Homekey program provides grants to local public agencies and tribes in order to acquire and rehabilitate properties like motels and hotels in order to transform these properties for primarily permanent, but also some interim housing for people experiencing or at risk of homelessness. $3.7 billion has been allocated to this program to be used over three years, and $2.8 billion of that funding has already been awarded.

The table on page eight provides an overview of that nearly $2.8 billion. As you can see, most of the funding went to communities in Los Angeles County, where over 4,000 units will be made available due to that program. Overall, Homekey has funded 210 projects across the state as of February 2021, which collectively are expected to create 12,800 housing units, again, most of which are permanent, and many of them are already in use.

Moreover, because these properties have covenants that ensure their affordability over 55 years, HCD, which administers the program, anticipates that these units would support 212,000 people over the lifetime of these units. Next, in 2018, voters authorized $2 billion in bond funding for the No Place Like Home Program to construct new and rehabilitate existing permanent supportive housing for people who need mental health services and are experiencing or at risk of homelessness. All of this bond funding has already been allocated as of August 2022, and the program provided 247 projects to support nearly 8,000 housing units.

The final program we wanted to highlight for you today is the Veteran Housing and Homelessness Program on page ten of your handout. This program is supported by $600 million in bond funding from 2014. The program supports affordable multifamily rental housing for veterans and their families. The table provides details on awards to various regions across the state as of December 2021.

You can see a total of $480,000,000 has been awarded or had been awarded as of that time, and once again, most of it had gone to Los Angeles to support nearly 3000 units. Since the data on that table, HP has made additional awards, and so they indicate that about $62 million remains available. There is a call for awards on that funding, and so far applications have sought out $109,000,000, and so we expect that once those awards are made, this funding source will be exhausted.

And so on the next page, we provided just a bit of context about bonds generally, as that is an issue of consideration before the committee. And here I'll just note that as of July 1, 2023, the total amount of authorized general obligation bonds and debts that remain outstanding for the state is $95 billion. That's a combination of $71 billion for bonds that have already been issued but not fully repaid, as well as $25 billion in bonds that have been authorized by voters but have not been sold as of yet. The 2023-24 budget package reflects nearly $7 billion in debt service for these general obligation bonds, or about 3% of the General Fund revenues.

These debt service costs are about as Low as they have been in recent decades and are about half of what they were at their recent peak, which is about 6% in the 2010 2011 fiscal year. And so with that context of existing programs in mind, all of which, once again, are either sort of exhausted or are nearly exhausted, on page twelve, we provide a brief summary of the $4.7 billion bond proposed by the Governor to construct and rehabilitate up to 1000 behavioral health units for residential settings, as well as housing for veterans and other individuals at risk or experiencing homelessness.

In particular, the bond proposes up to $865 billion in funding for housing, as the remainder of that funding would go to beds and community-based treatment settings for this residential care. And so the rest of the handout really provides our assessment of this bond. Once again, we do find that the bond is broadly reasonable. However, we raise a number of questions for legislative consideration. Many of these questions have already been raised by committee to the Administration.

So, for example, how would locals fund the ongoing costs to support permanent housing? We also have questions about the shortage of acute psychiatric beds. By focusing on unlocked, voluntary community based treatment centers, the Governor's proposal would not address the nearly 2000 acute bed shortage identified by the Rand study. And so, as there are different types of funds, different types of bed shortages across the state, some communities might be most affected, like the San Joaquin Valley and the north coast in this situation.

And so, in the interest of time, I will just sort of get to sort of our bottom line, which is to recommend a number of changes to ensure that the Legislature does have a more active and ongoing role. And so we would say that we recommend that the Legislature change from doing a continuous appropriation, which is what is proposed by the Governor, to have the authorization of the funds go through the annual budget process to ensure the Legislature has a more active role in doing this.

The Legislature could either sort of amend the statute or defer some decisions to a second year for such things as the methodology about how the bond funding would be allocated and who would be eligible for that Fund. And then we also recommend the Legislature establish oversight and reporting requirements to ensure you can sort of gauge how the bond is being implemented and that the goals are being met over time. Thank you.

Good morning. My name is Ky Le. I'm a Deputy County Executive with the County of Santa Clara, where my primary functions are to support our efforts to reduce and prevent homelessness and to increase and improve behavioral health services for residents with least means. On behalf of our County Executive, James Williams, happy to participate today. Thank you very much. First, I want to convey our appreciation for the substantial investments that the state has made in long-needed behavioral health treatment facilities and affordable housing.

Relatively recent capital programs like BHCIP and CCE, combined with older programs, for the first time represent a full continuum of housing and treatment options, from inpatient settings to temporary shelter to permanent supportive housing and to residential care facilities. We believe that the state should consider maintaining and expanding the portfolio for full continuum of programs, and projects funded by the housing bond or other sources should build on or expand on the exemptions offered under BHCIP and Project Homekey.

In Santa Clara County we've been working hard to maximize every opportunity the state has provided. With our $950 million housing bond as a catalyst, we coordinated local funding from cities, resources from our Housing Authority, and philanthropic funds from Meta, Apple, and Cisco through our partners Destination Home to more than double our supportive housing capacity in the last eight years, with a pipeline of 1,300 units countywide. While permanent housing options continue to be a priority, Santa Clara County and its partners have also committed to doubling temporary shelter capacity, and we have increased it by 66% and hope to reach 100% by 2025.

More recently, we've accessed the state BHCIP in Santa Clara County. and CCE funds to construct or start construction of a 77-bed acute care psychiatric facility, plan a skilled nursing facility, reviewing county-owned properties for mental health rehabilitation centers, open a 28-bed residential treatment facility and we are looking to fund construction of new residential care facilities on county-owned land.

We definitely believe that we have to make sure everyone has a home, but from time to time, we have to make sure that they are able to access the temporary treatment services that are necessary. And if apartments, even with intensive services, are not adequate, we need to provide other residential settings. While we encourage the state to continue to expand capital funding sources, our second recommendation is that the state authorize counties to directly administer funding allocations similar to No Place Like Home.

Communities with sufficient experience, infrastructure and development pipeline should receive a direct allocation of funds and be given the latitude to administer state funds to address local needs and to maximize local resources. For example, although the Rand study indicated a shortage of psychiatric beds at all three levels statewide, Rand's report for Santa Clara County showed that there were needs primarily in the subacute and community residential levels.

Keeping long range planning and coordination at the local level is also important because capital resources are only the start of the solution. As many of you indicated, treatment facilities, shelters, supportive housing programs require ongoing funding. Depending on the type of the facility or project, it is the counties or cities that will bear some of the financial risk. Each project's capital stack relies on braided operational funding plan downstream.

For Santa Clara County, that means that the county, city of San Jose, and others are coordinating expenditure plans for HHAP Behavioral Health, Bridge Housing, Emergency Solutions and one-time investments from Medi Cal Managed care plans. Keeping resources local can also reduce the uncertainty and thus allowing cities and counties to develop and implement long-range plans.

In that vein, our last recommendation is related to outcomes and planning. The state and counties and cities will continue to rely on a mix of funding sources. We believe that in order to achieve the state's objectives, the state should focus on establishing and simplifying clear outcomes, especially those outcomes related to housing and homelessness and then encouraging or requiring cities, counties, and other entities to submit coordinated expenditure plans. The state has already taken steps in this direction with some of its programs and should continue to do so.

The most important outcome, of course, are those related to the production of beds, housing units, and the number of people who are housed and to the percentage that retain their housing over time. Thank you.

Thank you. Good morning. My name is Chevon Kothari and I'm Deputy County Executive in Sacramento County overseeing our health and human service functions, including behavioral health as well as homelessness and housing programs. Thank you for having me today. Sacramento County really appreciates the intent behind the modernization proposal and the emphasis on increased behavioral health services and housing supports to our unhoused neighbors.

Yet we are concerned that asking counties to do more with less will lead to unintended consequences, reducing our ability to be effective with all of the populations we serve. As Dr. Kushel pointed out aptly sorry.

If folks could not applause during committee, that'd be great. Thank you.

As Dr. Kushel aptly pointed out, homelessness results largely from the lack of affordable housing. Housing costs have soared in Sacramento County, and we lack the number of affordable housing units necessary as we work to build more. We must also have the behavioral health services to both stabilize and provide ongoing permanent supports to keep folks successfully housed. The current proposal shifts 30% of our MHSA funding away from outpatient and crisis services to the housing bucket, while also adding a new group of clients experiencing substance use disorders.

Due to the way we leverage federal funding funding in Sacramento County, this equates to about $64 million, or about 65% of our outpatient and crisis services annual budget. Shrinking the pie reduces our ability to keep folks stabilized and housed. Individuals with serious mental illnesses have unique housing needs, and many require housing with a higher level of care, such as board and care programs.

Sacramento is rapidly losing board and care operators due to the growing cost of doing business, and we have used our flexible MHSA funds to incentivize board and care operators to house our consumers. Counties asked for changes to the housing portion of the modernization proposal to ensure that the funds can be spent on a broad array of flexible housing options. After recent amendments, funding is still narrower than under current law and adds restricted definition of housing supports and services like CalAIM.

These services are generally less intensive and more time-limited than most of our clients need. We are concerned that providers of permanent supportive housing may not have the flexibility needed to fund critical project-based components of their program, such as onsite supervision and related supports. Those who need housing within the behavioral health system often do not meet the federal definition of chronically homeless because of their time spent in treatment facilities or institutions.

We appreciate the intent to authorize DHCS to redefine chronically homeless to be more inclusive, but are concerned that many of the housing programs serving this population will still need to comply with the Federal HUD requirements, and we encourage DHCS to work with counties to develop this definition. We appreciate the language in the Bill that reduces barriers to citing housing for our clients by expediting, permitting, and potentially eliminating CEQA review.

We also support the urban county's request for language to ensure that merely allocating MHSA funding to housing projects doesn't trigger additional CEQA review or create unintended barriers for our development partners. The bond measure is generally a good idea for bringing more treatment facilities to our communities. After conducting a local Rand study, Sacramento County applied for and was awarded BCHIP funding for a mental health rehabilitation center, youth crisis facilities, and a substance use residential treatment facility.

Nonetheless, we still need more treatment facilities and beds to close our gaps and support our efforts to increase funding for this measure. We are concerned by the amendments that delink the BHSA from the accompanying bond measure. If the bond fails, counties would lose significant resources for treatment without a corresponding increase in new facilities or housing placements. Passage of the housing bond is also critical because of the limitation on capital funding for the housing under BHSA.

As written, about 7.5% or 25% of the 30% of the housing bucket can be used for physical housing units, translating to about $7 million annually for Sacramento County. We currently invest this much or more in current MHSA funding to leverage development projects locally. MHSA funds represent a very small portion of the funding needed to build housing units.

So in addition to the bond, we ask the state and our federal partners to continue to invest in housing development through low-income tax credits, mortgage revenue bonds, and the HCD multifamily housing program, amongst other solutions. I want to just appreciate your time today. And in closing, as much as we appreciate the intent of this legislation, this will shift and shrink the overall budget, which will impact treatment and services necessary for folks we serve to be successful in securing and maintaining over time.

Thank you, thank you. And next, please.

Good morning, Chairwood. Chair Wicks. Thank you for the opportunity. Committee Members. I'm Doug Shoemaker. I'm the President of Mercy Housing California. For those of you that are unfamiliar with us, we're a nonprofit housing provider. We work with seniors, vets, families, and other folks exiting homelessness. We're the largest nonprofit housing provider in the country, and we are also one of the larger permanent supportive housing developers and providers in the state of California.

We currently manage 2,400 PSH units and are in the process of developing another 1,200 in ten counties, including many of the counties represented here. We're excited to see this package moving forward, frankly, because we think it has the opportunity to fill a tremendous gap in the work and address some of the big challenges that remain in this work. In supporting the package, those of us in the housing and service provider community are hoping that the Legislature and the governor's office recognize that capital, the capital in these bonds is at most a third of what's really required to address the long term exits from homelessness.

I think it was asked earlier by Chair Wicks if there was sufficient services dollars or rental subsidy dollars to really support the work that is going on. I just, I'm sad to tell you that there isn't. And we're active in Los Angeles, Sacramento, Contra Costa, Alameda. Sacramento. Yolo. I mean, name a county Orange. And in most of those counties, they are struggling with both the rent subsidies available as well as the service. So I think it's vitally important that this effort move forward. But it's also equally important that the Legislature recognize that we are not staffing our current PSH as appropriately as we need to. And I heard excellent testimony earlier from Dr. Kushel and others on this.

So if we're going to expand, we really need to think through exactly how we're going to satisfy the needs of the new housing and the beds that are coming on, as well as address what I would consider to be a dangerous deficit in the permanent supportive housing system that we have today. There's currently a Bill in the Legislature, as I'm sure that many of you are aware, that could address one part of that by making PSH case management a benefit under Medical.

And I think that would be an enormous advance today. PSH providers like Mercy Housing and many others, I would say we're in an extremely fragile position, and I don't say that lightly. I think some of you are very familiar with the rise and fall of skid row housing in Los Angeles, which was a real tragedy.

There are lots of other providers, I think, teetering on the edge through a combination of different factors underfunding unrealistic expectations, and I would say a system of care in most counties that does not have enough service, intense options for the people it's trying to serve. And that's one of the main reasons I'm here today, is because I am excited to hear you all talking about assertive community treatment, but also talking about the opportunity for residential care and other versions of outpatient care.

This is not what we're typically able to provide in permanent supportive housing communities. I think we do excellent work. I think our partners and colleagues do excellent work. 80% to 90% of the referrals and people that are referred into our buildings, and those of our colleagues do extremely well.

And there's a small subset that frankly need much more support than we're able to offer in the buildings that we currently have and those of our colleagues, and they need that additional level of support if they're going to succeed. And the impacts are not just felt by the individuals who don't have that level of support. It's also felt by staff and the other residents of these buildings when we don't have the appropriate support necessary to help folks live independently in community like this.

You can see this in terms of skyrocketing insurance rates for permanent supportive housing, very significant financial losses that many of us are encountering, as well as incredibly high staff vacancy rates and turnover, particularly among social work professionals and others that are directly dealing with residents. So I don't want to sound like I'm negative about this. I'm actually quite positive about the opportunity, and we're very excited about the option.

I just want to note that this is not a single-shot solution, and I want to acknowledge that Chair Wicks has been appropriately advocating for the fact that we also need a more broad approach to affordable housing. There is simply no way you can solve the epidemic of homelessness in our state by rushing to the scene of the fire. We need the upstream approaches, and that includes more housing overall and more affordable housing.

And so, as you're considering this bond and this measure, I would also just commend the Legislature to continue to do what it's been doing, which is to provide the much needed capital for broader affordable housing development. Because we simply cannot just focus on permanent, supportive housing and expect to end homelessness as we see it here in California. So thank you.

Thank you. We will bring it back to committee. Mr. Arambula.

Thank you, Madam Chair. I'm going to stick with Lourdes Morales if I can, and you'll notice a similar theme both speaking about data and then our children and youth. So I'm going to speak about the Rand study, which you mentioned, which specifically looked at our adult populations and excluded children and youth. And I'm looking towards what the LAO had commented on as that raises concerns about whether we have information regarding children and youth and their needs for both psychiatric beds and community residential beds.

That I'd like to know to what extent we are expecting or anticipating the resources from this bond to be spent on children and whether or not the Administration anticipates that the proceeds will fund and be focused on specific populations like our children and youth. Hoping you can comment on that.

Thank you. Mr. Chair, Ryan Miller from the LAO. Yeah. The Rand study acknowledged that the matter of children and youth needs for behavioral health beds was outside the scope of their work because of the unique needs that children and youth have. We did ask the Administration about this, and the Administration did point out that the bond funds would be available to go to children and youth facilities.

I think that the real reason that we were pointing it out as an issue for legislative consideration is that relative to the work on adult needs that Rand had done, there seems to be a little bit less that's been done on the scope of that issue. And so that's something that we think the Legislature will want to continue to have a role in, as Lourdes was stressing, with ongoing oversight and implementation work.

I bring it up again. We can spend the money, but we're not mandating spending that money. And oftentimes we struggle getting upstream when we're not providing that resiliency early on in their life. And so when our children and youth are living on the streets and being traumatized, as we heard about earlier, it's awfully hard to expect different results. And so I'm wondering if this is a blind spot for us since we didn't study it with that Rand study, how do we make sure that we're using these bond revenues appropriately to address the children and youth?

We would sort of just say generally that we do think that this is sort of an area where there is an interest for sort of more legislative oversight from our perspective, where you could sort of take a more active role in not only sort of its design but its implementation. So the recommendations reflected in our handout, but also in our longer piece online, do sort of identify sort of key questions where the Legislature may want to weigh in, such as target populations that may be of interest, whether you want to do set asides what is the allocation methodology. And so those are all spaces where the Legislature can not only take an active role initially, but then also, through establishing oversight mechanisms, ensure those goals are met over time to ensure the bond success.

Thank you.

Thank you.

Mr. Wood yeah, and I'll be very brief here, but I want to go back to the Benioff study Dr. Kushel talked about today and her work in that there's a paragraph here on the third page. I just want to read this because I think it's an important piece here that I hope that we can address. And I don't believe it's going to happen with this particular Bill, but I think it's something that really needs to be brought out.

And I think Mr. Shoemaker here actually alluded to that. Actually not really allude to it. He talked about it, and this is quote here even if the cause of homelessness was multifactorial, participants of the study, of which there were 365 that were detailed interviews, believe financial support could have prevented it. 70% believe that a monthly rental subsidy of $300 to $500 would have prevented their homelessness for a sustained period. 82% believe that a one-time payment of 5,000 to 10,000 would have prevented their homelessness. 90% believe that receiving a housing choice voucher or a similar option would have done so.

And I point this out because what jumped out at me is we are spending $189,000 per honky unit, and as we see a growth in the home, we've seen growth in the homeless population. I wonder if this investment in subsidies could help prevent some of that. It's not going to solve the people that are already homeless, but how could we be incorporating that somewhat in our homeless policy? Housing policy? So anyway, that's my comment. Thanks.

Great. Well, thank you, Mr. Wood, for that. I wholeheartedly agree, and I just appreciate, Mr. Shoemaker, your comments around the broader need for more funding for rental assistance, for production. There's a lot of needs here when it comes to housing. I wanted to ask Mr. Le since you have done some supportive housing in your community, do you share the concerns around the need for ongoing funding and do you see if this moves forward as is? Do you currently have the resources you need on the ground to continue to do and support the ongoing funding that you need to support this community?

Thank you for the question. I would say that we agree with some of the Assemblymember's comments and Members of the panel that we should be focused on expanding and increasing one-time or capital resources and additional ongoing resources to provide full range of treatment, housing, and services. The administration's focus on housing and reducing homelessness are commendable. We support that. The expansion and inclusion of people with substance use disorders only is also important. But ultimately we need additional resources or additional flexibility to maximize the resources that we have in order to meet clear outcomes from the state.

Thank you. I think that will conclude our session. Panel number four, we will adjourn for lunch. We will be back at 1:30 with panel number five and the meetings. Adjourned for now. Do you want to gavel us?

Okay. This is recess.

Not we're not adjourning, we're recessing only. Yes, apologies. We will be back at 130.

Thank you. Good afternoon. We'd like to reconvene our hearing and thank you very much. Just a couple of things before we get started here. We have two more panels and then we will have our agenda, as our agenda says, we will have 30 minutes of public comment. Now, I see a lot of people here and 30 minutes will go by really fast.

So those people who if you're going to provide public comment and you have a position of against or for and can just say that rather than elaborating as to why that would be helpful to those if you're following somebody else's opinion, in other words. So I will also note that the committee does accept and will continue to accept written comments through our portal. We read those, we take those into consideration.

We do have, should this Bill pass out a committee today, it will be going to appropriation. So this is not the end of the line, quite honestly. There's a ways to go here. Just understand that because after this informational hearing, we will go into the Bill hearing and a more traditional Bill hearing environment there. So just keep that in mind as you prepare for your public testimony.

I know that our panelists, if we could ask them to speak up clearly and deliberately if possible, that would be really helpful. I know everybody's timed and everybody's trying to get every possible word in here, but if we could just sometimes it's hard to hear, and when we're looking at some of our closed captioning, it's hard for them to keep up. So if we can keep that in mind during your testimony.

So with that, we're going to have our next panel, our behavioral health proposal panel come up. We've got several folks and we will ask them, each panelist, to self introduce as we go along. And that'll save us introducing twice. And you all know the orders, so that shouldn't be a problem. Okay.

Hello. Thank you, chair and committee, for having us. My name is Will Owens with the LAO, here with my colleague. And today we're going to be presenting our analysis of the Governor's behavior health modernization proposal as represented in SB 326. So we released a number of posts evaluating the Governor's proposal, but this was as of the July 13 version last week. There has since been a number of amendments that have made significant changes. And so yesterday, our office released an update post identifying some of the key issue areas that we believe have since changed thanks to the amendments.

So today I'll be focusing on mainly how our analysis has changed. But first, I just want to touch on some issues that we raised for the legislatures that we think are ongoing. So generally, we find the administration's analysis of the proposal to be incomplete. In particular, we raised questions regarding how the proposal will, on net, improve behavioral health outcomes given the shift in funding focus. Additionally, we provided an estimate on the statewide impacts of the shift in funding categories.

However, it's unclear, especially when you get to the county-by-county level of what those impacts would be and we found the analysis for that from the Administration lacking. So, that being said, the three areas that I would like to highlight from our original post that we included in our update are issues on county flexibility, children and youth spending, as well as the role of the MHSOAC or the Mental Health Services Oversight and Accountability Commission.

So first, on county flexibility, our previous analysis we found that the administration's initial proposed funding categories, which focused on full-service partnerships, housing interventions, and then behavioral health services and supports, it shifted the funding towards FSPs or full-service partnerships and housing interventions. And generally, the categories were more prescriptive than what is under current statute. This reduced the amount of flexibility that counties had to spend on a number of different services.

And so consequently, the Legislature faced a trade-off between ensuring certain types of programs were funded as well as utilizing local expertise. So, under the amendments adopted last week, the proposal does give now some flexibility to counties in terms of how funding can be used, in particular allowing a certain percentage of each category to shift between categories. Additionally, there were some provisions of the amendments that allowed for greater flexibility of small counties to adjust how much funding in general could be used for housing interventions specifically.

So the amendments allowing counties to shift the funds between the categories may actually help mitigate some of the issues in terms of funding for current services that we highlighted on our original post. Particularly, counties can move a portion of funds from housing interventions and the FSP category to the behavioral Health Services supports category, which, as we noted, we estimate to be over prescribed based on current levels of funding.

However, the net impact on current spending is still unclear given that especially counties will have discretion on whether to pursue this flexibility, as well as there's discretion on the part of the Administration to approve this shift in funding. So while like I said, there is increase, it is a little unclear.

Next, I'd like to talk about the children youth spending portion. So under our previous analysis, we noted that while there is a regulatory requirement currently to require a portion of prevention early intervention funds to be used for children and youth, under the proposal, there was no such statutory requirement included. So under the amendments, there is now a provision that requires over half of early intervention funding as well as the population-based prevention funding to be used for children youth aged 25 and younger.

I just wanted to note in addition, that we had raised concerns that the definition of children youth under the prior proposal did not include transition-age youth, typically those 16 to 25. But the new definition now seems to include this. So, as counties currently use not just MHSA funding under the PEI category, but also in FSPs to target children and youth, it's a little unclear to what degree this statutory requirement that's now included could potentially increase the amount of funding for children and youth.

However, we do note that it will ensure at least a minimum level of funding for children and youth services, particularly those, as I mentioned, in early intervention and population based prevention. Finally, we just want to discuss the role of the OAC under the proposed amendments. So we found that the governor's initial proposal would have removed most of the commission's current oversight, regulatory and programmatic authority over MHSA funding.

So given the lack of the analysis by the Administration for why this was prudent, we recommended that the Legislature reject that piece of the proposal and maintain the commission's oversight and regulatory priority setting role. Now, under the revised proposal with the amendments, we do note that there has been some shift towards more role and authority for the OAC. However, most of this is as an in consultation role or providing technical assistance to counties.

However, we find generally that still the priority-setting rulemaking authority and some more general oversight is still lacking. So barring any additional justification provided by the Administration, we maintain our recommendation to keep the OAC's authority as it is currently.

Thank you. Ryan Miller LAO we also wanted to cover the issue of revenue volatility and the reserves proposal, but acknowledging the conversation that's already been had this morning, the comments by the Administration and I think their apparent commitment to be working on this issue. We wanted to really focus on more of a framework for the Legislature to consider in terms of how to think about tackling this important challenge. So I wanted to really focus on two concepts.

The first being we would urge the Legislature to match the level of reserves to the revenue volatility. There's nothing inherently problematic about wanting to reduce the amount of allowable reserves, but really the issue is that if it's proposed without an accompanying change, that really addresses the severe volatility of the MHSA tax, that really can put some undue fiscal risk onto the counties. So we would urge the Legislature to be trying to kind of match those up.

And as we have found, if there wasn't a change in the tax, we actually think that the reserves should probably be quite a bit higher than they are in current law. So we've offered some ideas in our analysis for how to address the volatility as we've recommended. Some of them involve swapping or say, shifting the millionaires tax to the state General Fund and then taking a part of the state's revenue system and moving it to the MHSA.

And some of the ideas that we've offered we think could reduce the volatility by two-thirds, still maintain healthy growth for counties in the long run, raise the same amount of revenue over the long run, and also really only result in a small marginal increase in state revenue volatility because the state General Fund is so large and it can absorb that well.

But we also want to acknowledge other ideas that have been presented by the counties, and I think the secretary even spoke to the possibility of the rolling average notion. Those ideas seem to be promising as well. I think the other thing we wanted to speak to is to try to be mindful of the whole reserves policy, too.

There's obviously been a lot of focus on the allowable caps and the volatility itself, but there are also rules in the MHSA about how much counties can deposit in a given year, how much they can withdraw, when they can withdraw, and especially if the revenue source remained somewhat or as volatile as it is now. We think that the Legislature may want to consider more flexibility for counties and when they can make deposits and withdrawals. So with that, we'll look forward to questions after the panelists finish. Thank you.

Thank you.

Good afternoon, Chair, Members. Thank you for having me join you today. I'm Karen Larsen. I'm the CEO for the Steinberg Institute. As a therapist, I served the underserved population, undocumented, unhoused population for more than 20 years in community clinics and nonprofit settings. And just prior to joining the Steinberg Institute, I was the Health and Human Services Agency Director for Yolo County, which was an integrated agency with social services, public health, and behavioral health services, all under one agency.

The Steinberg Institute was founded by mayor and co-author of MHSA, Darrell Steinberg, and we're a nonprofit public policy agency dedicated to transforming the systems of care for mental health and substance use in California. And since our founding, we've really tried to serve as stewards of the MHSA. The MHSA was born out of two pieces of legislation, AB 34 and AB 2034.

They were authored by then Assemblymember Steinberg, and these bills really established the whatever it takes approach to care for people experiencing homelessness with significant behavioral health conditions. And they had great outcomes. They reduced homelessness, incarceration, and hospitalization dramatically. So in 2004, based on that premise, the voters overwhelmingly approved the MHSA to scale this model statewide and with the promise of ending homelessness amongst those with behavioral health conditions.

Nearly 20 years later, without proper state oversight and guidance, we've strayed from the MHSA's original intent of focusing on serious behavioral health conditions and homelessness. Current MHSA rules require the majority of funds for services to be used for this whatever it takes approach. But out of the ten California counties with the highest homeless population, only Orange County is following the MHSA's spending standards.

Between 2019 and 2022, Orange County saw a 17% drop in people experiencing homelessness, while the rest of the state saw homelessness rates continue to rise. This isn't a coincidence. Over the last decade, funding in our behavioral health system has more than doubled, but the rates for those receiving care haven't improved. At the same time, we've seen homelessness, incarceration and hospitalization for those living with significant behavioral health conditions skyrocket.

In our recent analysis published earlier this month, we found SB 326 to be not only in keeping with the original vision of the MHSA, but an urgent and necessary plan to care for our most vulnerable. First, SB 326 sets critical priorities to fulfill the intention of the MHSA. Until now, California has not set clear statewide priorities for behavioral health spending in General or for the MHSA.

SB 326 focuses the nearly $4 billion in MHSA revenue to target the most intractable issue of our time homelessness amongst those with serious behavioral health conditions. At the same time, FB 326 preserves critical early intervention dollars and set asides for children and youth. Second, the Bill doubles down on outcomes and accountability. Failure to establish standard metrics and properly track, evaluate and improve outcomes since the passage of the MHSA has been one of the biggest failings of the current act.

Our systems must be able to account for improving the lives of those living with the most significant behavioral health conditions, especially when it comes to homelessness, incarceration, and hospitalization. Third, SB 326 adapts the MHSA to a new funding landscape. California has invested billions of dollars in a complete overhaul of our statewide behavioral health network via investments in youth mental health, commercial insurance coverage, desperately needed mental health infrastructure, and a first-in-the-nation expansion of Medical.

SP 326 accounts for how these new investments interact with the MHSA. To ensure that we are being the best stewards of the public dollar and meeting the needs of Californians, we honor the hard work and dedication of our partners at the county and provider level and acknowledge the tremendous challenges they are facing in terms of workforce and competing priorities.

We believe that we must all work together to focus resources and services so that California can achieve the greatness we are capable of in caring for those living with the most significant behavioral health conditions, facing the worst possible outcomes. We believe SB 326 will do just that. We are grateful for the unparalleled leadership from Governor Newsom and Senator Eggman and are proud to support SB 326. The Steinberg Institute is committed to working with the Legislature, Governor Newsom and our partners to seize this moment and realize the vision of the MHSA. Thank you.

Chair Wood and Members, thank you for the opportunity to testify today. I'm Kendra Zoller and I am Legislative Director at the Mental Health Services Oversight and Accountability Commission. Our Executive Director, Toby Ewing, sends his apologies that he is not able to be here today. At the outset, I'd like to recognize the considerable work of the committee on this legislation and their efforts to bring clarity to what is a very complicated and significant Bill.

The committee staff went out of their way to be available to discuss the Bill under tight deadlines. As many of you know, California's Landmark Mental Health Services Act was passed to support transformational change in our public mental health system. It emphasizes tailored care for those struggling with the greatest mental health needs. It calls for early intervention so that we may move away from decades of rationing access to care, and it requires a broad definition of prevention that is focused on supporting well-being, including preventing homelessness.

There has long been tension over whether limited funding should focus on those with the greatest needs or support prevention to get in front of those challenges. The Governor's proposal is timely and highlights areas where we have failed to do enough housing addiction prevention, early intervention, including early psychosis, and leveraging opportunities to tailor care through full-service partnerships. On behalf of the Commission, I'd like to thank Secretary Ghaly and his team for the time they have spent with the Commission to understand our concerns.

First, we strongly urge the state to not tie its own hands through a ballot measure of a vote of the people is not needed. The scale of these changes will undoubtedly result in unanticipated challenges. The Governor and the Legislature must be able to amend and adjust over time. Second, flexibility is always preferred when feasible. The Commission is concerned that the fiscal categories for state funding may not be sufficiently flexible over time.

We would recommend the committee explore whether funding for prevention, workforce and state operations can be allocated through the annual budget process, with a general 10% set aside of BHSA funding. Rather than establishing fiscal silos up front, that flexibility will allow the state to adjust funding allocations over time based on evolving needs. Third, the Commission is concerned about the loss of innovation funding. Under the MHSA, the state and counties have leveraged the existing 5% set aside for innovation to support fundamental improvements.

For example, Solano County used innovation funding to rebuild its community outreach strategy, resulting in improved access to care by more than 300% for underserved communities. Today, more than 40 counties are exploring opportunities to replicate their success. The Commission is also working with nearly a dozen counties to improve access to early psychosis interventions. Unaddressed psychosis is a major driver of homelessness, hospitalization, and criminal justice involvement, with tremendous costs that can be avoided with evidence-based care.

This effort began as a county innovation project, and the state has stepped up to expand the reach of these funds. Counties have also used innovation funding to support criminal justice diversion and support school mental health. New approaches to housing, mobile crisis services, integrated electronic health records across counties, stigma reduction, youth empowerment, ER diversion, and more have been funded with innovation dollars. To be clear, innovation in mental health is happening every day through the private sector.

But the benefits of that work do not always find the most vulnerable Californians in our public mental health system, the MHS funding set aside for innovation ensured that the most vulnerable Californians do benefit from innovative approaches. While the Bill states that counties are expected to be innovative in all that they do, it is unclear how that will happen without a fiscal mandate.

Fourth, the Commission is very appreciative of the work that has been done on school mental health with the passage of the Mental Health Student Services Act and CYBHI. While many of the fiscal reforms included in the CYBI will continue after its sunsets, California's commitment to school mental health isn't not one of them. Therefore, we should encourage sustained leadership on school mental health, perhaps following this effort.

Fifth, we also appreciate the focus and restatement of a commitment to accountability. The state and counties have not yet fulfilled that commitment despite the statute, and we look forward to working with the Administration to develop an implementation plan to ensure we get there. Lastly, the details matter and how the state and counties implement these reforms will determine if more Californians can access care and achieve recovery.

For one, it will be important for the Legislature and the public to be able to monitor implementation of these reforms over time. Second, it will also be important to ensure that implementation sufficiently engages the clients and families served by the behavioral health system. One explicit goal of this reform should be to eliminate disparities in behavioral health outcomes, and the best way to do that is to improve how we engage and listen to California's diverse communities. BHSA implementation should be co-created with the communities are the most underserved.

Lastly, as I mentioned before, it will be important to have flexibility in state-level funding to ensure we have the ability and the funding to support an implementation plan that matches the scale of this reform. Thank you for the chance to join me today and happy to answer any questions.

Good afternoon, Chairs and Members. Thanks so much for having me here today. My name is Phebe Bell, and I'm the behavioral health Director for Nevada County and past President of CBHDA. Image to say has completely transformed how we deliver specialty mental health services in California over the last 20 years for the better.

It has given us the opportunity to make true investments in prevention, early intervention, and to build a more robust continuum of outpatient service is in fact an independent, peer-reviewed study out of USC found that thanks to the MHSA, we've prevented over 500 deaths by suicide in California today. The MHSA has become a core source of funding for a broad range of safety net services.

It makes up one-third of our state dedicated funding streams, and it's a crucial source of local match for medical dollars. It's also transformed how we deliver care by requiring us to more meaningfully engage our local 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 disorder conditions, a lack of access to housing for our clients, and the opportunity for more transparency about our services and expenditures.

And I want to be clear counties are not only open to increased transparency and accountability, we sponsored a Bill authored by Assemblymember Arambula that was passed by this committee to do just that. We're invested in helping our state partners to better understand the good work we and our community partners do every day. As has been described a number of times today, we wanted to share the impact of adding a new requirement to divert a third of the MHSA funding to housing.

You can see up here that the pie gets sliced up differently than it was before. Initially, we were looking at somewhat comparable levels for prevention and earlier intervention and full service partnerships, but we were concerned about the core services funded through the BHSS category or the dark orange slice here.

And although we appreciate that the state has attempted to respond to those concerns, what's happened is we've lifted 4% of the funding out to the state level, which reduces the overall pot, meaning that there's a modest gain to the BHSS category of 2% and an overall decrease in funds. Those prevention dollars today support our school-wide prevention activities, including community stigma reduction and outreach efforts, particularly in our BIPOC and LGTBQ, and immigrant communities.

For this view, we tried to look at the impacts of the funding when we add substance use disorder services and divert funds to address those needs. And I want to highlight that in 2019, CBHDA and CSAC worked on a joint set of MHSA reform principles which called for using MHSA more flexibly for SUD-only services.

So while we are aligned with this goal, 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. For this slide, BHDA asked to sample small, medium, and large county to model how our existing programs and services would translate to the new funding categories in a more granular way using current expenditures. Unfortunately, the reduced funding we see here does not account for the new requirement to further divert funding for the SUD requirement.

And this modeling exercise really just confirmed at a county level what we saw at the system level, which is a significant drop in that dark orange general services bucket anywhere from 50% to 80% across counties. And again, this is the bucket that funds core outpatient crisis and peer support services. As many of you have addressed today in your comments. These services are also largely matchable through medical, which would increase the impact of the losses to our committees with the related loss of Federal Match Dollars.

To say that another way to cut $100 of MHSA from a program, we generally have to cut $200 of services. So this slide is a deeper dive into the impacts on my county, Nevada, where it looks like I'll need to move about three-quarters of a million dollars out of my $4.3 million for FSP that I currently spend in order to meet the required spending in the other categories. And this would all be if funding were only spent on mental health services.

We would also likely lose 1.6 million in medical revenues. I want to add a couple of comments as well about the housing bucket and some concerns we have. We are worried about fixing a much larger broken system, which is the supply of affordable and adequate housing in our state on the backs of the behavioral health system.

And to make that explicit, in Nevada County in 2022, we went after every dollar that the state generously has put forward to improve housing in our state, and we applied for all of it. We added 71 beds of housing to our community, which we're really excited about. And in that same year, 200 people became homeless for the first time. We also are worried about how to sustain the housing that's in that bucket. We cannot get vouchers, permanent supportive housing vouchers, or housing choice vouchers. And I think that's a discussion needing more attention.

We also are concerned about the services, the non-treatment services that need to be funded in that bucket, the pieces that allow housing to be successful for really, this is a picture from our peer respite program that we operate with, MHSA dollars. It's a beloved program and the kind of program we worry we may lose. And lastly, just want to touch on the volatility issue, which the LAO folks also highlighted there's kind of two issues to the volatility.

One is it's hard to predict funding source. But secondly, when you start having rigid funding categories, it's very challenging to manage your money and be able to expend in a timely way. So, for example, two years ago we had a million dollars more revenue than we planned for. We wanted to spend it on housing, but we couldn't because then our GSD bucket would be out of proportion with our FSP bucket, which needed to be 51%. And so we are stuck because of those rigid categories.

In closing, we believe 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 believe we have an opportunity to address some of the challenges of MHSA by smoothing out the volatility. We believe that it's important that foundational laws such as 91 and 2011 Realignment remain untouched through this process and instead are addressed through the normal processes of a negotiation between counties and states.

And we continue to ask for special consideration for rural counties based on the unique challenges we face. 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 funds in partnership with the community in ways that best meet the needs of our community and prevent suffering and even death for thousands of Californians.

Good afternoon, Chair Wood and Members of the committee. It's an honor to be back before you today. My name is Zach Friend. I'm Chair of the Santa Cruz County Board of Supervisors and I'm also here today representing all of the state's 58 counties on behalf of the California State Association of Counties where I Chair the Health and Human Services Committee. As you know, no program or no initiative or no Bill can succeed without the implementation of counties.

And I wish I was here today to tell you that we felt that the Bill that's proposed, even with the amendments, went far enough to do that. But I don't think I can quite say that. I think our county, the 58 counties here have a significant number of concerns as proposed in order to implement this successfully. And we're at a defining moment. As all of you know, you've had amazing leadership on this.

A housing crisis in our state, behavioral health crisis in our state, homelessness crisis in our state, and these issues shouldn't be put at odds or conflict with each other. These are things that need a symbiosis, they need to have an interrelationship. And the funding mechanism shouldn't take away from one worthy cause for another.

As Dr. Arambula said in an earlier panel, as I think also you're well aware, the expanse of what's being asked for of our state's counties right now can't be overstated from CalAIM to Cal Courts and the timeline to implement all of these. Taken individually, any one of them would be a lot. And we want that responsibility on behalf of the counties. But you can't do it while simultaneously taking away resources for one and asking us to do more and reporting for two.

I think that what we do understand the Legislature and the Governor understands is that all things being equal, we're in the service delivery business, not in the reporting business. But this, as proposed, would create more accountability, as it's called, but more really reporting requirements and less service delivery availability for the state's county. So let me say what it will do, because I'd heard Assemblymember Fong ask some of these questions earlier.

It requires counties to do more, to serve more with less funding and less flexibility and direct to Dr. Weber's questions earlier. It reduces funding for core mental health services. It'll reduce our ability to leverage federal funds. It diverts funding from one worthy cause to another. We need funding for all of these causes. And I think it creates holes in a safety net where we're going to have additional vulnerable people fall through those holes. We can get there.

The amendments and I appreciate the great work of Chair Wood here, the amendments are getting us there, but we're not there yet. And the counties want to make sure that we're at the table to ensure that we can get there with what's being proposed. Specifically, the county's concerns are on the 30% set aside. Obviously, there needs to be flexibility or additional discussion on that. As the LAO noted, there needs to be some way to address the volatility.

It feels like that's getting closer, and I think that'll be resolved. But that's not the major issue, right? I mean, the major issue is that money is literally being taken out of the hands of counties where we need to provide other services with that. And last is that we want the unfunded mandates to be removed from the proposal. I think that we can all agree that there are a lot of requirements that are being put on our local governments right now to provide service delivery.

And these things take time to actually effectuate. They take time to become real. And we at the county level are going to be the ones implementing this for years to come. Well past the time that this hearing occurs or this decision is made, we want to make sure that we recognize five years or ten years from now we've made a fundamental difference in these people's lives that we're talking about right now, and we can't do it under the current proposal. Thank you, Mr. Chair, for the honor of coming back. It's wonderful to be here and be pleasure to answer any questions you may have.

Great. Thank you very much. I'm going to turn to the committee for questions. Questions or comments. Dr. Arambula.

Thank you. I'm going to begin with. Karen Larsen, if I can. I was really drawn towards your comment regarding FSPs and the ten largest counties with homeless populations and nine out of ten of them not meeting our state standard regarding funding for FSPs. That I'd like to understand how we have confidence that any other types of mandates that we are requiring, insisting upon, will be met if that FSP one is not currently being met.

I'm not sure this is a question that I can answer for you because it seems like it's definitely in the administration's realm. As I understand it, there hasn't been a mechanism for holding the counties accountable to the FSP requirement within that CSS bucket at the moment, and that would be remedied in this new BHSA.

I bring it up in light of the comments that Kendra had stated regarding flexibility is preferred, as my understanding is this was a temporary flexibility in 2010, 2011 due to budget circumstances, and yet counties have continued to spend less than what they're being mandated for at the state level. That I question whether we're utilizing those resources with whatever it takes model to the maximum capacity and what is being asked of us.

I know you, Phebe Bell. I'd like you to give some thoughts to that and how we ensure that we are providing guidance while allowing our county partners to be able to implement effectively.

Yeah, absolutely. And I think what's important to note is that counties are operating in accordance with existing law, which is that you spend 51% of your money on FSPs, but that's utilizing the federal financial participation dollars as well. I also want to add that in my county, we are spending overspending on FSP, and yet we still have a homelessness problem. Just the act of having FSP does not solve the core structural issue of inadequate supply of housing.

And while, as we heard earlier, we need those critical supportive services absolutely. And we need them to be funded adequately so that we can impact as many people as possible. It's got to be all of it.

I'm going to follow up with you, Ms. Bell, if I can. You had also made a comment about cutting MHSA funding and what that would equate to with county spending. Is there a way to validate that number or to verify, as it would seem, that there's multiple funding streams coming in, and not all of them qualify for federal participation, financial participation? That I'd like to make sure we're speaking with real numbers, and I'm hoping to follow up, and it can be offline about how we ensure what you were speaking about is accurate.

Yeah, 100% happy to share some of the background documents we use to develop sort of the analysis on a county by county level of what these cuts would mean.

And finally, for Mr. Friend sorry, wanted to you said that counties are in the business of service delivery and less in reporting. I'll highlight again, earlier today we heard with FSPs that a third aren't giving us demographic data. So while I hear you in implementing and doing service delivery, I also want to make sure we're getting appropriate data so that we can address some of the disparities that we've seen within our system.

We've heard what happens to our indigenous populations and African Americans, that I think you similarly have a role here to help us with reporting of data that I don't think it's an either or. I think it should be both.

Yeah. Dr. Arambula, I agree with you fully. Let me just say that what we're dealing with is a situation, and you would have known this through the MediCal work and both of your work before that, the requirements have gone up exponentially. The available staffing has gone down as well. So we're a third down in Santa Cruz County. Most counties have about 20% less behavioral health staff.

So a lot of our staff is now dedicated to grant-based reporting or programmatic reporting and not the service delivery. So what I'm saying is that right now, I agree it's a Hobson's choice, right? It should be both. But if what we're talking about is a reduction in funding, then I think ultimately we have to ask ourselves, as legislators, which I'm at the local level, what is our ultimate goal? And I don't think our ultimate goal is the reporting side, is the service delivery side, or we need to grow the pie so that we can do both. But the choices, that's what we're faced with.

Thank you, Mr. Chair.

Anyone else? I guess it's a post-lunch coma that set in. Know I'm going to go back. Ms. Bell, obviously you're here, you represent a rural county. For the five counties I represent, actually, all five could be classified as rural. So I'm curious, from your perspective. What kinds of flexibilities, what are you looking for to implement if it ends up being exactly what we have before us? What changes would you like to see?

Well, I think, as amended, there was some exceptions given for rural counties, which was great to see. We really appreciated that progress. But as I understand it, it's a process to apply for that exception, prove your case, have it granted, and I think often that can be time-consuming and slow and might not allow us to be as nimble as we need to be. So I think automatic exemptions for certain categories of things.

For example, some of the planning expectations, some of the percent of money to be spent on housing doesn't make sense in some of our tiny communities where their point-in-time count is less than ten people and they're going to spend 30% of their money on housing, for example, or where there's not five large cities to pull to the table or some of those kinds of pieces. So having just a much more simple process for rural counties to use these funds in a way that makes sense in those different settings.

I appreciate, I think simple makes a lot of sense and barring simple technical assistance because we know the smaller the county, the less number of people who have the expertise to actually do the work. And while Supervisor Friend, I appreciate the concern about reporting, as Dr. Arambula said, we need that data. We absolutely need the data. But just collecting the data is only a piece of it. It needs to be analyzed and processed.

And my impression is that the data that has been analyzed or collected hasn't really been analyzed and processed as it should be, which is part of the issue there as well. But we absolutely need the data. From my perspective.

Chair Wood? If I may on that, just for Mental Health Services Act reporting as counties, we turn in an extensive amount of information to the state, hundreds of pages of very detailed analysis of the programs that we funded. And I think one of the challenges is it's not uniform right now. And so there's no real easy way for the state to sort of absorb that and disseminate it back out to the community at large. But if you go county by county and look at their annual plan reports, I think you'd be impressed by the level of accountability that exists.

So there is no uniform requirement for.

Data reporting or is your not in ways that you could easily say 6 million people receive service X or whatever you'd have to sort of fairly manually, I think, pull it from different reports.

Okay, I appreciate that. Appreciate that feedback. Let's see. Ms. Zoller. So we heard from the LAO who we met with and we've talked with your folks as well, the changes in the oversight piece of this by MHSOAC. Hard question. I mean, this has moved from where it was an introduction. I would imagine the position would be we'd just like it the way it is now. Is there something else short of that? Is there some other new additional middle ground that we could get to?

Because I recognize absolutely and respect the valuable role you play in this. There are oftentimes when we need information as a committee or individuals that we can go to you and we can get the information where it's often harder for us to get it from other agencies. So I appreciate the value of what you provide there and don't want to see that piece of it diminished.

So not asking you to get in hot water with your boss or anything, but can you push us in a direction to tell us is there something that's absolutely critical that's missing from the amendments and where we are now?

Yeah, thank you for the question. The commission does not have a formal position. We are going to be discussing the Bill on Thursday at our commission meeting. So I think some of that will be discussed. But we do have ongoing conversations with the Administration about our statute and the changes they've made and their productive conversations, specifically about the data sharing. And so those conversations are ongoing.

Okay, appreciate that. And then, just more of a comment than anything else. I just want to thank you. The Lao's office, you've been incredibly accessible. Obviously, some of your concerns we shared, and you've seen some changes in the amendments moving forward here. As always, appreciate your candor and your constructive approach to providing us with potential pathways. We do know that obviously, there's still work going on how we address the volatility issue here.

But I just want to thank you again and appreciate the work that you provide. Okay. All right, you just walked in. Okay. With that, I want to thank this panel, and we will go ahead and move on to our final panel. We're kind of in the home stretch, sort of this phase of the day, so we've got a larger panel and there may not be enough seats, so maybe when the first speaker is done, we can create another spot for someone.

But please don't leave, because we undoubtedly will have questions. So I'm going to let you all know the order. So I'm going to let you self introduce in the interest of time. So when the first panelist is ready to go, please go.

Great. Good afternoon. My name is Cheryl Winter. I'm a licensed clinical social worker, and I promote health and homelessness policy solutions with the Corporation for Supportive Housing, a national nonprofit. In a prior position, I provided Assertive Community Treatment, also called ACT and Supportive Housing, to people experiencing chronic homelessness, living with serious mental illness, and active substance use disorders. The solution to homelessness begins with housing, and data supports the concept embedded in SB 326 that ongoing funding for housing interventions is a health intervention.

Once housed and receiving the right services and supports, people with behavioral health conditions can live independently, recover, and thrive. Yet the funding in SB 326 and AB 531 alone isn't sufficient to end homelessness or the behavioral health challenges homelessness causes. California must invest an additional $6.9 billion, or about 2.5% of our state budget each year, to solve homelessness.

This is why California must also pass the Housing Bond Chair Wicks has introduced AB 1657, as well as enact ongoing funding for housing and services for all experiencing homelessness. Decades of data show that supportive housing works and has prevented and ended cycles of homelessness and institutionalization. Those studies relied on evidence-based service models like Assertive Community Treatment Teams or act teams. ACT is a multidisciplinary, team-based model that provides intensive outpatient services for people with serious mental illness and co-occurring disorders.

In the continuum of evidence-based care, ACT offers the most intentional, ongoing, and comprehensive supports. ACT teams are available day and night, evenings and weekends. Right now, most California communities don't have act teams. People who face challenges living alone in support of housing with current underfunded housing case management are the very people that ACT was designed to serve.

This underfunding in services and property management is causing a crisis in our supportive housing industry in California. ACT and other intensive service models are expensive, but they are far cheaper than institutional care. We recommend ensuring behavioral health reform funds. ACT teams in Housing and California can go a step further and use MediCal Fund both act in support of housing and a housing support services benefit.

We also recommend clarifying that counties should be able to supplement CalAIM community supports with BHSA services and that housing-based CalAIM-funded supports shouldn't substitute or be the sole source of supportive housing services unless they are funded and structured to align with evidence-based models like Assertive Community Treatment.

We further recommend improving other provisions in SB 326 and AB 531, specifically, expanding eligibility for housing interventions to anyone with a behavioral health condition or who exhibits symptoms of a behavioral health condition. Additionally, the list of housing interventions in SB 326 should include master leasing, move in costs and incentives for landlords to take rental assistance.

Lastly, we recommend language that builds in more inclusivity and racial equity, specifically including provisions that track and report progress in reducing racial disparities in housing and service referrals, service delivery and referrals to licensed institutional settings, and including people with lived experience of homelessness in planning and decision making. Advisory boards and commissions referenced in SB 326 thank you for inviting me here today.

Good afternoon, Chair and Members. Andrea Rivera, Associate Director of Legislative Affairs with the California Pan-Ethnic Health Network. Decades of failed mental health and housing policies have forced communities of color to face the brunt of an unequipped social safety net. BIPOC communities have the highest rates of unmet mental health needs and are more likely to experience trauma from discrimination. CPEN supports the intent of SB 326 to strengthen our behavioral health safety net and focus services, including housing intervention supports, on those who are most vulnerable.

We agree on the importance of addressing housing and substance use treatment as equity imperatives and appreciate what CalHHS described as the equity anchor. However, as written, the proposal lacks an explicit focus on identifying, reducing and eliminating racial disparities and may in fact, have the unintended impact of worsening mental health outcomes for communities of color. We have three concerns that I'd like to share at this time.

First, the proposal originally required counties to provide substance use disorder services with BHSA funds, and this is incredibly important given the disproportionate impact that SUD has within communities of color. However, recent amendments now remove this requirement. While counties must report dollars allocated for mental health versus substance use to DHCS, and the Department may ask for alterations to plans and budgets, there is no minimum requirement or definition to determine what may constitute an appropriate allocation.

Communities of color living with SUD have a history of misdiagnosis and inaccessible treatment, and this ambiguity leaves significant potential for continued bias and discrimination. Second, nothing in SB 326 requires counties to demonstrate how the BHSA dollars will be used to combat and reduce racial disparities in communities. We strongly urge the Governor and Legislature to add these essential provisions so resources can target the communities most in need.

Equity cannot be expected as a byproduct of a policy that does not intentionally or explicitly seek to undo entrenched social drivers of racially inequitable outcomes. Third, and finally, we cannot modernize the entire behavioral health system by advancing a proposal that continues to minimize the obligation of health plans to provide behavioral health services to Californians. MediCal managed care plans and commercial plans have an obligation to provide treatment, and SB 326 requires them to participate in the integrated planning process.

But there's no requirements in the proposal for health plans to actually improve access to care or outcomes, and again, not to reduce racial disparities. Communities of color need a behavioral health system that utilizes all levers across the continuum of care to minimize instances in which Californians fall through the cracks of our institutions. Thank you.

Good afternoon, honorable Chair and Committee Members. My name is Leslie Napper. I am a proud resident of Sacramento County, a Senior Advocate with Disability Rights California. But above all, I am a peer survivor of the battles waged against us living in the realm of mental health disability. I am here to share my piece of my story and my concerns regarding SB 326.

I remember well the origins of the MHSA that started with Prop 63. As a black person and a person living with serious mental illness, I stand here as a testament to the transformational power of culturally reflective, responsive, voluntary, community based mental health services. I vividly recall the shadows of stigma, self stigma. My microphone went away. The strain on my families. I lost my place. Can I get some time back?

I think if we call the shadows of stigma, self-stigma and the strain on my family, the glaring absence of culturally responsive, community-defined practices that were grounded in culture and tradition, the cultural awareness and mental health support my path towards wellness. Living within the Bipolar Schizoaffective spectrum brought me into the embrace of peer-run, respites crisis centers, wellness centers, and community-based voluntary outpatient care that are culturally reflective and possible by MHSA, CSS, PEI and innovation dollars.

Through these service provisions, I learned to navigate my symptoms, manage medication, and build the coping skills that sustain me to this day. However, SB 326 threatens to dismantle the very foundations upon the lives which upon the foundation upon which lives like mine have been rebuilt. This Bill, if unchanged, could divert essential funds away from community-based, voluntary, culture-responsive, outpatient mental health services that are the lifelines that many of us depend on. California's mental health crisis demands a multifaceted approach.

Housing first initiatives and robust community mental health services are intertwined and interdependent. However, allocating 30% of MHSA funds to the housing threats to mental health services that are the backbone for our sustained wellness. To sacrifice one for the other would be a disservice to our community's wellness and promotes differential treatment, especially towards our communities of color. I implore you to reject the current form of SB 326. Our lives, our wellness, our families, our communities are at stake.

Instead, let us consider the voices of those of us that are directly impacted in these decisions. Let us forge a Bill that stands as a testament to unity, compassion, and genuine care for the well-being of individuals. Let us usher in the changes that enhances lives and nurtures recovery and dignity of every individual. Let us remember the faces and stories and journeys that are behind these services. Stories of resilience, strength, and triumph over adversity.

I stand here before you not just as Leslie Napper, but as an embodiment of countless voices, each yearning for the chance to reclaim our wellness. As you deliberate a path forward, let us infuse transparency in every decision and let us amplify the voices of those of us with lived experience. SB 326 is an opportunity to demonstrate our dedication to the well-being of our community. Let us seize the opportunity.

In conclusion, I implore you to one, ensure peer involvement by establishing a Lived Experience Advisory Board and requiring the board to be consulted on behavioral health policy. Two, inquire a robust stakeholder engagement process, not just at the three-year plan, but also for the annual updates, which are even more critical now if they're going to be able to use the flexible up to 14% spending from another bucket.

And three, preserve critical MHSA funding for voluntary, community-based, culturally responsive, such as services such as peer-run wellness centers, crisis respites, and mobile crisis units. Please always remember that our lives are hanging in the balance. Let us work together to preserve the essential services of MHSA provides and that have been the lifeline for thousands of Californians like me. There should be nothing about us without us. Thank you so much for your time.

Appreciate just waving, please. No outbursts, no clapping, please. Respect our process, please. Thanks. I'm not sure if Jessica Cruz is here, apparently, so we will go ahead and move on to Lishaun.

Thank you, chair and committee Members. Thank you for the opportunity to address you today. My name is Lishaun Francis, and I'm with Children Cow. Children Now is a statewide research policy and advocacy group that focuses on the whole child. Despite the amendments last week, Children Now is still opposed unless amended on SB 326. The Bill, as it stands, still leaves out key populations and continues to ignore the impact the overall changes will have on children.

Today, I'm going to spend a little bit of time talking about where we think the gaps still are in the most recent round of amendments. Unlike the prevention and early intervention carve out, most of what we're asking for doesn't exist within the MHSA today. But our experience in the last 20 years, combined with the new programmatic pressures this Bill presents, has proven that greater protections for kids are needed.

One of the things that many of us in the children's space really recognize is that even within the kids world, we tend to forget about our book-end populations. And our book-end populations are best described as those who are zero to five. And our transition age youth, so older youth, and that's primarily because there's no formal system that supports them, like school-age children in schools.

So, for example, in our experience with the MHSA in its current form is that there's been a lot of work to ensure that little kids, so infants and toddlers, are thought of on the local level. The state vocalizing its desire to support small children through a set aside in the prevention and early intervention buckets could go a long way. And that's primarily because PEI models look very different for infants and toddlers. Investing in our zero to five population not only helps small kids but also families.

Next, we've always been a big fan of the Full Service Partnership Program. Currently, the FSP program has a population that is about 50% children and youth. The anything-goes approach has worked well for families and youth. However, with the expansion of the target population to include those with SUD needs as well as the expectation for FSP to support individuals in care court, available funding for FSP programs for youth will clearly be crowded out by these additional demands on the already finite pool of dollars.

That is why we think it's even more important in this iteration of the MHSA for youth to get a set aside under the FSP bucket. Lastly, we are requesting a set aside for unaccompanied youth under homelessness. We've heard the administration's desire for flexibility, but I do want to point out that in the latest amendments, there are already set-asides in homelessness. It's described as, and I quote 50% shall be used for housing interventions for persons who are chronically homeless, with the focus on those in encampments. End quote.

We know that people in encampments tend to be adults. So in essence, and with respect to the Administration and its stated desire for flexibility, there is a set-aside, just not one for youth. We believe it's critical to have separate housing supports and services dedicated to young people that's designed to meet their unique needs. Many of you up here already know that the current set-asides in current state programs such as HAP and Homekey have been quite successful.

While we do want to thank the Administration for being willing to work with us on the prevention and early intervention bucket, we also want to be clear that what we're actually saying is that while nothing in the Bill requires a cut to services. Intellectual honesty would have us admitting that by not increasing the 1% tax and adding additional pressures to counties, both political and fiscal will amount in cuts to services. We're asking you not to mortgage our future to do so.

Good afternoon, honorable Chair and Members. I'm Sherry Daley, the Vice President of Governmental Affairs for the California Consortium of Addiction Programs and Professionals. We represent over 20,000 addiction-focused professionals, more than 120 treatment programs, 350 recovery residences, and thousands of people in recovery throughout the state. We also certify, train, and represent SUD peers.

There is not a space that we operate in that won't be touched by the Governor's Behavioral Health Modernization Proposal, and we are proud to support the tremendous system improvements we believe it will bring. The most obvious improvement is the inclusion of substance use disorder throughout. When Proposition 63 was drafted in 2004, stigma toward people with addiction was rampant.

Studies in 2000 and 2004 revealed that people with substance use disorders were generally considered to be more responsible for their conditions than people with depression, schizophrenia, or other psychiatric disorders, and there was a persistent belief that a substance misusers illness was a result of their own behavior. Thus, in turn, this influenced attitudes about the value and appropriateness of publicly funded alcohol and drug treatment services.

It does not take a tremendous amount of consideration to come to the realization that the exclusion of substance use disorder services from the proposition was born from stigma. We now have the opportunity to remove the artificial barrier to resources that was predetermined by Proposition 63. We can reflect what voters of today will assuredly support the treatment of the whole person, regardless of one's primary condition. The modernization proposal focuses on the need to house people, particularly in early recovery.

Recovery housing has been associated with numerous positive outcomes, including decreased substance use, reduced probability of relapse, lower rates of incarceration, higher income, increased employment, and improved family functioning. CCAP wholeheartedly supports the emphasis the proposal places on encouraging supportive housing as a means to address the cyclical nature of remission and relapse. Without opportunities to put into practice recovery skills, adhere to medication management, and reintegrate to society and family, resources are simply being diverted to short-term solutions to complex medical and social ails.

Without support of housing and wraparound services, we will continue to see relapse and additional self-blame people feel for failing treatment. Again. We literally are teaching many people that treatment doesn't work under our current system. In addition to focusing resources on housing, CCAP is also grateful for the recognition the proposal gives to the need to increase the workforce. There have been significant resources applied to mental health workforce needs, yet only recently have we seen resources applied to the substance use disorder profession.

There are tremendous long-term needs that must be addressed if we are to expand treatment, to meet current demand, and to staff the various programs passed by the Legislature to improve access in education, incarceration and hospital settings. California has no license for alcohol and drug counselors. Because colleges and universities teach to licenses, there are very few Bachelor's or Master's programs offered for the profession. Thus, those wishing to progress in the behavioral health field must leave the profession to pursue degrees. Already?

I thought we had five minutes. I'm sorry. Where degrees are offered, SUD counselors entry level have turnover rates of 90% at one year. We must do better to retain our critical workforce. We also must commend the drafters of the proposal for including SUD representation, both by those with lived experience and by professionals at every part of the process. In planning through to implementation. We also appreciate the data tracking ideas that are involved in the Bill.

We have been on the forefront of innovation in what's called recovery capital tracking, where people actually interact with the tracking system, report how they're doing, provide longitudinal data to see how our treatment programs are doing, and are excited about those opportunities. We commend the Legislature and Administration for working on this it's a heavy lift. We ask our clients every day to make hard choices and to change, which is difficult, and we are in full solution mode with you to make this happen. Thank you.

Good afternoon. I'm Dr. Mary Ann Dewan, Santa Clara County Superintendent of Schools, and I'm representing a coalition of more than a dozen education, labor and management groups, including CTA, the California County Superintendents, AXA, CFT, and many others, to share our recommendations. My staff emailed the coalition's revised joint letter describing our requested amendments to the committee last night.

We are grateful to the Legislature and the Administration for recent historic investments and policy changes that increase support for youth behavioral health and is moving California toward an integrated systems approach. These efforts are positive steps towards alignment and coordination between schools and health providers. I also want to share a gratitude to the Assembly Health Committee for the recent amendments, which included several of our requested and recommended amendments in our original letter. Thank you. From the education perspective, addressing the needs of the whole child is necessary.

Research tells us that when children are hungry, experience anxiety and stress, and have emerging mental health needs or untreated trauma, their brains cannot process information effectively, and schools must meet the physical and behavioral needs of children while also providing quality curriculum and instruction. The recent historic investments in MHSSA and Children and Youth Behavioral Health Initiative reflect the fact that children and youth are 21 times more likely to access and benefit mental health services when they are provided on a school campus.

Providing services at school significantly reduces primary barriers to youth mental health access, including transportation cost and community stigma. We appreciate that recent amendments to Senate Bill 326 restored the provision requiring 51% of early intervention funds be spent on children and youth, and we note that none of this funding is currently protected for school-based behavioral health services, which are a necessary part of our state's whole child approach. Our coalition is requesting additional amendments to ensure that prevention-based dollars are protected for children and youth.

Education representatives are included on local mental health boards, and case managers include schools and care coordination. A few have argued that Prop 63 will no longer be necessary funding source for school-based behavioral health programs because of new one-time grants and billing options. That perspective reflects a fundamental misunderstanding of both the types of services that children most need and the limitations of one-time funding and billing for school-based services.

It's now widely accepted that other than the most severe cases, diagnosing children with a mental illness is not a 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. Yet children still need services to mitigate the onset of behavioral health symptoms, promote healthy self regulation skills, address adverse childhood experiences and trauma, and support their school attendance, engagement, and learning.

Unfortunately, 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. While helpful for startup and one-time expenses, community schools and the CYBHI do not provide ongoing funding, and billing options do not fully cover the cost of services. PEI is therefore critical to creating a continuum of care for children. Several counties are already demonstrating how PEI can fill the gaps in funding for student mental health.

Just a couple of examples. Solano County currently allocates 8 million to Fund 40 student wellness centers on school campuses. And LA County provides 10 million to LUSD for trauma and resilience-informed early enrichment programs. In Santa Clara, nearly 20 million for school link services is budgeted. If our coalition's proposed amendments are adopted, these programs would be maintained and modest additional funding would be available to grow school-based behavioral health programs. Thank you.

Okay, thank you. Thank you very much to everyone. I'm bringing back to the committee questions or comments from the committee. Dr. Arambula. Thank you.

I'll begin with Lishaun Francis, if I can. I was really moved by your comments about the success we've had within HAP and Homekey that I'm hoping you can expound on that, as I believe it's important for us to look at what happens when we house our children and transitional-age youth.

Thank you. And I will admit that I probably cannot speak to it as well as some of the Members on the panel, but what I do know is that about 10% of HAP was set aside for youth housing, and we saw a 21% reduction in youth homelessness since 2020 as a result of that. So that is, some say would say a really successful rate.

I think it would be a logical reason for us to be considering whether we similarly put a set aside for children within housing as well. In light of the fact that FSPs over the last five years have predominantly been children and youth 67%, is there also not a logical argument to be made to have a set aside for children and transitional-age youth?

Yeah, I think so. I mean, we have been very vocal about that need, particularly as counties are going to struggle with figuring out how to serve folks with Sud needs as well as the new reference codes to the care court population. So we're really concerned that young people who tend to not be as visible, right?

So they tend not to be on the street, they tend not to be living in encampments, and oftentimes they tend not to be showing the kinds of signs of mental illness that a lot of adults will show. And so we're really concerned that they will get left out of this.

I'll finally uplift the importance of focusing on zero to five as a subsection. The home visiting program that we have as a state has shown tremendous success when you focus with intentionality where people need that resiliency and believe that that's another strong rationale for us to make sure that we are considering focusing on those bookends as you so eloquently put. I'll shift now to Ms. Rivera if I can.

I think for many of us on the dais, we were following and listening to what was occurring with substance use disorder. But the lack of mandate that came through the recent amendments will dramatically affect the ability for us to treat concomitant disorders that we know occur between mental health and substance use disorder. That I'd like to get your take on what you think that would mean by not having a minimum requirement for SED

Yes, and thank you so much for that question. Assembly Member, in kind of taking a bit of a step back here for us. When we first saw this proposal, I think we were excited about that opportunity to really take a look at how we can holistically ensure that we're encompassing behavioral health.

And I think the challenge that we bumped into with the more recent round of amendments that now make the substance use provision optional is if we're making something optional, then we don't actually know if that's going to happen or if it's going to take place. And I think the whole vision for this proposal in the way that it was shared from the very beginning is that we're taking a really deep look at how we can actually ensure that people are getting access to care.

And if we're making it one of the core provisions, right, the substance use piece optional, we don't necessarily think that brings us closer to our goal.

I would just say we're changing the name from mental health to behavioral health, which means we're to be inclusive of SUD, and yet we're not mandating SUD treatment for each county. And I think that's problematic as we are seeing the overdose rates that we have as a state and the importance for us to be making those investments. I'll pause there. I look forward and appreciate very much this panel finally, just if I can. Look, I think it's important to call out Leslie Napper.

I think it's important when we have people with lived experience and nothing we do should be done without you. And so I'm glad and appreciative that you're here and raised your voice and spoke up today. Thank you, Mr. Chair.

I know, Ms. Quirk-Silva

Thank you, Mr. Chair. Thank you to all the panelists and everybody who's been here all day listening to that. I know some of you are actually working in the field and work in tight budget constraints almost daily to get to what you're really there for, which is to serve people that need help desperately. That being said, I've heard a lot today that I agree with, but there are some things that do concern me. If any of you know who I am.

I'm Assemblymember Sharon Quirk-Silva and I've been a bulldog on housing. But what concerns me here is, of course, I support housing for all in many different levels. So whether it's our young people entering the workforce, of course, whether it's keeping people housed so they are not being evicted, and certainly individuals living in encampments. But the concern here, as has been mentioned a few times, which is we're saying we want to now add housing as part of this menu without necessarily the allocated funds.

I'm a public school teacher for many years, and I've seen this menu before, which is do more. You now have additional things to do, but the same constraints, whether it's the hours in the day to cover material, and it simply ends up not working. That being said, there is some responsibility on local governments and counties. When we mentioned the HAP funds and some of those programs that we know have been successful, Orange County has 34 cities.

Only four cities in Orange County took advantage of applying and attaining those funds. So there certainly have to be more efforts for the resources we do have. I'll just end with on the SUDs discussion. I was an author on a Bill that actually led to accepting that there are co-occurring conditions that people endure.

And too often we have systems that are making people that are very vulnerable navigate not only many different offices that could be difficult for anybody, but sometimes individuals that don't have transportation that are suffering from anxiety, many times they're individuals that have been released from prison. And now they're working with probation officers that are saying go here, go there, go over there. And you already know the outcomes for that.

It's like having that same parent navigate three offices at a district office, and maybe they don't speak the same language, and it's like, go here, go there, and Why isn't your kid going to school? I've seen this firsthand, and we have to do better, and we can do better. Like I said, I think there's some things to cheer here, but there's also some places that we need more amendments.

I'll be presenting a letter from the Orange County supervisors about some of their concerns, and we need to take those concerns and amendments seriously. Thank you so much.

Mr. McCarty.

Yeah, thank you. I know it's been a long morning and afternoon, and we addressed many issues, and you want us to kind of not copy other issues. And so one issue I hadn't really heard much about, maybe somebody could address, and this is kind of broad, maybe I don't want to paint an overly simplistic picture here, but to some extent, Prop 63 are discretionary more for the counties. It's easier to pick programs.

A lot of government funding sources, like MediCal, are more complicated to figure it out. And so I've heard some reports say that, for example, it's easier to use Prop 63 on some children's mental health programs than signing them up for MediCal. But we have multiple problems we're trying to solve. We're trying to help mental health services for all human beings, adults, adolescents, super little kids, teens, what have you, and also provide more housing. So everybody is for more housing.

So if it's just the bond by itself, more housing for people with substance abuse disorders or severe mental health issues, we're all for that. But the issue here is how do we pay for it? And so we're modernizing Prop 63. I get that. I think it's time to reevaluate this after a decade or two decades. And the gist is that by doing so, we're taking 63 flexibility away to do things like adolescent mental health.

I guess the question for us is that what can we do to make us utilize medical more efficiently? In other words, what else do we need to be doing besides because you're saying, don't do this because this takes away our ability to use that money for over here and why can't we have our cake and eat it too? Why can't we do both? So we're picking and choosing.

So what do we need to do to actually make it so we can use more MediCal because we can't use MediCal to build housing? We know that there's some programs for housing, but it's not that easy. So we're trying to flip it here. So help us answer that.

I think it's a really good question and I think this tension between Prop 63 and MediCal has come up often. So there are two issues. The first issue is the one that you brought up, that there are things that MediCal can pay for that we're not using medical for and that has to be fixed. A lot of that is tied to the administrative burden that small organizations find with trying to Bill MediCal and try to work through that really quagmire of a system.

But the second issue is something you also highlighted and that is some things MediCal simply won't pay for. So for example, while housing is one, you can't draw down FFP for undocumented youth, for example. And we know that the MHSA pays for a lot of services, mental health services for those who might be undocumented. So we're really looking at this broadly. I think there are two categories here of conversation when you're talking about what MediCal will pay for and what they won't pay for.

So what could we do different? Is there anything that we can do in state law to make it easier for MediCal for adolescent mental health?

I'm sure that there is. This is not necessarily my expertise if I'm going to be completely honest. I try not to make a habit, to speak on things that I don't know a lot about. But what I will say is the state is trying to do some things to lessen the administrative burden. I think there are people in this room who could probably talk to you a bit more about what that looks like and how well that's been going.

I guess it's the reason you can answer, too. The reason it's the issue is because you're saying, don't do this, because we can't use that money here. Let's figure out how to use that money here, and then we can use this money for a clearly needed investment, which is 10,000 plus housing units for people who need care.

Yes. So, Assembly Member, I want to also be clear. I'm not saying don't do this. I will say that I think what the Administration has presented to everyone here is a false choice. And a false choice is one where you either do X or you do Y when there are multiple options. So you could raise the tax, for example, and have more money in order to do more for young people and for the homeless and for the SUD population. So I'm not really forcing that narrative, to be frank. I think that that is a false choice that has been presented by the Administration.

Thank you.

Okay. Is there anyone else? I just want to say thank you, especially to this panel. I think this is a really important panel. I appreciate that. I did have one brief question, which just because a lot of this got my attention, but there was something I expected a lot of testimony, but there was a question that came up, or something came up by Ms. Winter. Now we're talking about housing, supportive housing. So you said we need incentives for landlords to take rental assistance. Explain that to me. I mean, the landlord shouldn't care what the money looks like if they get paid. So explain to me what that means, because I'm not a housing.

So yeah, so in the same way that an earlier panel, Mr. Shoemaker, talked about ongoing operating costs in permanent supportive housing, if people don't have the level of supports and services that they need at the right intensity, then there may be challenges for them remaining housed. And there's great stigma attached to housing someone who is exiting homelessness.

So for landlords, they have very real concerns around property damage, around what other neighbors might think and really just the costs if they are going to receive a rental subsidy. We found that incentives and even help paying first and last month's rent or a higher security deposit or in a shortage of housing, a fee to hold the unit for a couple of days if you have to go find someone who it may take some assertive outreach to do that. So that's what we're talking about.

Appreciate that. Thank you for that very much. Okay. Thank you very much to this panel. I appreciate your testimony. I want to thank everyone for being here today. We are going to begin taking public comments. I think. We have the very first one is going to be Mr. Hector Ramirez was by prior arrangement is going to get the first public comment. I will remind you we'll be starting the clock. It's 30 minutes of public comment.

So the briefer you are, the more people that get the opportunity to speak. Idea. Hang on a second before we start. So the more direct and brief you are, the more people will get an opportunity to speak. But we do have a hard stop in 30 minutes and each person will have up to 1 minute and then we'll have to move on. Okay? So please go ahead. Hang on.

Ramirez. And I say it because it doesn't say here the Mental Health Services Act was funded it is funded by millionaires tax on land, on native lands. Yet we have seen, I am Hector Ramirez. I am an actual consumer of Los Angeles County Department of Mental Health for the past 23 years. I'm an actual person with a lived experience. I'm not a paid lobbyist. I'm not here with an organization.

I'm speaking here on behalf of a quarter of a million consumers from Los Angeles County. I left LA County this morning early after having dealt with a hurricane and an earthquake. But as I left this morning, my homeless and unhoused individuals reached out to me offering me their recycle money, offering me to drive me here because of people with individuals with disabilities, we're not represented by any of the experts you have here.

So I really want to really point out that out, and one of the recommendations coming from the largest county in the United States with the largest public mental health system in the world, I ask that as you do this the Mental Health Services Act has failed us. It has failed Native American population, it has failed the California native population, it has failed the Latino population, because it has not really focused on our communities.

Right now, with our unhoused population, we see and we ask that as you do this, we want this, but really including there as a private type population, our Native American, our tribal communities, our LGBTQIAs communities, and our disabled population, which is all the people served by the Mental Health Services Act, but it hasn't done it. I go back and thank you. Thank you.

Sorry. Good afternoon, chair and Members. My name is Courtney Armstrong. I'm here on behalf of the First Five Association of California, and we want to align our comments with that of Lishaun Francis from Children Now. We remain although we appreciate the amendments and the inclusion of children zero to 25 in the prevention and early intervention funding, we remain opposed unless amended to include a specific set aside for youngest Californians ages zero to five.

We're specifically asking for 20% of that 50% be set aside or designated for that population. Just to answer the question that was asked on the MediCal reimbursement, we know that for children zero to five, about 95% of the services that are currently provided by MHSA funding do not meet the criteria for MediCal reimbursement. Our counties, currently our youngest Californians, currently rely on that funding, but we know the need is so much more.

I also just wanted to point out that even with the PEI set or aside requirements that are in place today for zero to 25, county mental health departments are not required to prioritize or address the needs of children's ages zero to five. Thank you.

Thank you. Good afternoon. Tara Gimbo Eastman with the Steinberg Institute in support and align my comments with those of our CEO, Karen Larson.

Thank you.

Good afternoon. Joel Baum, Director with Safe Passages, one of 35 organizations comprising the California Reducing Disparities Project, which is a historical effort to address the disparities we find for our LGBTQ and BIPOC communities. The Governor's current proposal explicitly separates prevention and early intervention funds. If this artificial split is to remain, it is imperative that CDEPs, community defined evidence practices specifically mentioned earlier by Director Baass, be eligible for funding from both buckets to reinforce this idea.

So, again, critical that CDEPs are able to be funded by either one of those PEIs. To make that reality, one, we must remove the language that prohibits services to individuals under the prevention umbrella. Two, we have to ensure CDEPs are able to provide early intervention and prevention services if funded under early intervention. Three, we must assure that the early interventions are not requiring a diagnosis.

And finally, early interventions must allow for, and fund services, individuals who are at risk, but not necessarily showing signs of mental illness. We also must include representation on the various boards associated.

Thank you. Next speaker, please.

Good afternoon, Andi Liebenbaum. On behalf of Los Angeles County, we sincerely appreciate your work and the work of your staff on addressing this issue. The thoughtful and detailed analysis in advance of the bill's hearing. After this hearing, like many here, we're still carefully reviewing last week's amendments and waiting and looking forward to the additional amendments that may be published shortly. We look forward to working with this committee, with the Senate Health Committee, and our county coalition partners on any other needed amendments and next steps.

We appreciate the work the Administration has done so far, and we applaud and appreciate your leadership. Dr. Wood, Los Angeles County will remain actively involved to get SB 326 to a place where we can successfully implement it.

Thank you.

Good afternoon, Stacie Hiramoto with REMHDCO, the Racial and Ethnic Mental Health Disparities Coalition. I want to align my comments and thank my colleague Joel Baum, so I won't repeat those about CDEPs, or community defined evidence practices. They must be able to be funded under both prevention and early intervention.

And I really want to thank Dr. Arambula and Members Quirk-Silva and Weber for talking about issues that are important to not only REDMHDCO, but the California Reducing Disparities Project, including representation on oversight and advisory bodies that specify membership of both LGBTQ and BIPOC communities. Because we need a seat at the table. Thank you so much.

Thank you.

Hello, I'm Cristopher Bunnell. I'm representing San Joaquin Pride Center. I am a seat up that Joel and Stacey both go ahead and both mentioned. I just want to go ahead and make sure that their sentiments are heard as well.

Good afternoon. Rebecca Gonzalez with the National Association of Social Workers, California chapter. I want to thank you for this thoughtful discussion we've had today. I do think it illustrates how much work still needs to be done, and I look forward to seeing additional amendments. I want to align my comments with Joel from Safe Passages and Stacey Hiromoto with REMHDCO. Thank you.

Thank you.

Good afternoon, Serette Kaminski with the Association of California School Administrators. I just want to align my comments with Ms. Francis from Children Now as well as Dr. Dewan. Just want to also reinforce a comment that Dr. Dewan made 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 long period of reduced socialization with peers.

As she said, children and youth are 21 times more likely to access and benefit from mental health services when they're provided on a school campus. So it really is critical that these services are protected with these funds. And we also want to make sure that schools have representation on local mental health boards as they determine how the county will allocate the Prop 63 funds.

Lastly, ACSA wants to caution against the reliance of CYBHI dollars in lieu of MHSA funds for youth, since that is one time funding. Thank you.

Thank you.

Hi there. Rachel Bhagwat with ACLU California action. I'm here to quickly comment that a top goal in California's mental health system should be to reduce mass incarceration and criminalization of people with mental health needs. And so we urge the Legislature to protect funding for outpatient treatment programs needed to implement our 2018 mental health diversion law and other bills since then.

Counties already don't have enough funding for outpatient diversion, and we're worried that this reform could make it even harder to divert people into these programs that provide rehabilitative opportunities for folks who are involved in the criminal system for mental health reasons. Also, any reform should explicitly protect mental health crisis programs that reduce police contact during mental health emergencies. We must allow counties to sustain investments in mobile crisis teams, peer responders and more. Thank you.

Thank you.

Good afternoon. Lisa Coleman with the Commission on Aging. We urge this committee to remember the unique population of the older adults, aligning ourselves with the comments that Dr. Crucial said this morning the fastest growing segment of the homeless for the first time are those over the age of 55.

We urge you to consider with the behavioral health oversight that you look to having two positions, not just an older adult and a disability, but a unique voice for both, because a young person with disabilities is going to have a very different perspective than an older adult with disabilities. Thank you.

Thank you.

Good afternoon, chair and committee Members. My name is Danny Thirakul with the California Youth Empowerment Network. I would first like to say that we appreciate the amendments to include a TAY Member on the OAC and on local mental health boards. However, we believe that a minimum requirement of spending for outreach and consistent engagement at the local level is needed to ensure involvement for all stakeholders, tay and peers. Secondly, many TAY cannot access services on campus. They rely on services off campus.

I myself was unable to access services in high school because there were no services for LGBTQ youth. Any services that were available weren't focused for my community. Our most underserved populations, LGBTQIA plus, BIPOC, justice involved, foster youth are at risk of losing services. And so that's why we oppose the Bill.

Thank you.

Good afternoon, chair. Committee Members. Karen Vicari on behalf of Mental Health America of California. We are opposed to the Bill because, as we heard from Dr. Kushel earlier, homelessness is an affordable housing problem. We cannot divert necessary mental health funds away from services towards housing. We need to find another way to fund housing. And I would like to align our comments also with Leslie Napper. Thank you.

Thank you.

Good afternoon. Avery Hulag-Vicente, California Association of Mental Health Peer Run Organizations we'd like to echo the comments of Leslie Napper, the previous panelists from Disability Rights California. We oppose SB 326. The input of the leaders from the peer BIPOC and LGBTQIA plus communities were integral in crafting the MHSA and shaping its intent and structure. And its passage was a win for us in building a mental health system for the community and by the community.

However, these last few months, we've been frustrated with these continued attempts from the Administration and state legislators to dismantle and restructure the MHSA in the form of SB 326. We agree more investments must be made to expand services across the board, but don't take away the investments from the communities who are currently being served in an already overburdened public system.

Despite our advocacy efforts, we feel unheard and unseen as this Bill is continuing to shift, change and move quickly through the legislative process without our voices considered. Thank you.

Thank you.

Good afternoon. Leah Barros. On behalf of California Hospital Association, we are pleased to support the important changes proposed to modernize behavioral health. Behavioral health emergencies in children and youth, impact the entire spectrum of emergency medical services, and because of this, we support efforts for a set aside to help preserve existing MHSA funded programs for children and youth.

We would also like to see changes that would, one, consider the needs of those who are on involuntary holds or 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 hospital. Thank you all for your hard work and dedication on this important and timely issue.

Madam Chair. Mr. Chairman. Josh Pane. One short and small thing that needs to be done is connecting this in between group. And I've proposed a group of amendments that would focus our attention on the probate code. The probate code actually focuses down on a group of people who are caught in between a big group out on the streets right now, and that probate section would give them a guardian angel rather than a full fledged conservator.

So I would appreciate your attention to that and I think it would better the Bill so that once you pass this and the people pass it, then there's something in between the sidewalk and volunteering to come in and 51 50 the LPS. So I appreciate it. Mr. Chairman. Madam Chair. Thank you very much. Thank you. The sergeant has my proposal.

Good afternoon, Chair Wood and committee Members. Adrian Shelton with the California Alliance of Child and Family Services. We represent nonprofit community based organizations across California that are serving children and youth and families in public human services systems.

We can't say this strongly enough, our youth are in crisis and the needs of the youth and the children who are coming into our member agency programs have only increased since the pandemic, and the authors and the administration's recent amendments on the prevention and early intervention component are exactly the right direction. And we are further requesting prioritization of children and youth when it comes to housing and housing support.

Nearly one in four Californians who struggle with homelessness are unaccompanied youth or families with children, and one in four foster youth are exiting the foster care system directly into homelessness. So we believe that these populations need support to prevent them from becoming tomorrow's homelessness population. Thank you very much for the thoughtful hearing today.

Thank you.

Good afternoon. Clechio Bozo, Alameda County. I want to say that we've talked a lot about the need for racial equity and challenges with racial disparities experienced by our black indigenous people of color. But this Administration has a habit of doing things and cloaking it and not actually making it equitable. So BIPOC communities were not consulted in the creation of SB Three, Two, Six and white supremacy is changing the bedrock of MHSA without community input, without lived experience.

White supremacy has us deciding what works for people without asking us. White supremacy has us cutting a pie over and over again instead of talking about raising the tax on millionaires. What I heard today was that rent is too high and it is not a mental illness problem. I heard that the state is doing nothing on housing affordability and blaming this on mental illness. We have to actually address housing affordability. Also, 4% is not enough to fund prevention for our BIPOC communities.

We need community defined practices funded in prevention and early intervention. The data has been saying yes. So sorry. So thank you. I oppose SB 32 Six, and I ask you to take it off the March ballot. Thanks.

Thank you.

Good afternoon. My name is Zakiya Johnson. I'm from Alameda County and I work for peers. Peers envisioning engaging and recovery services. We offer programs to help create non judgment spaces where people could come and feel safe, receive peer to peer support and skills and tools to help them maintain wellness, recovery support and stability which is at risk and being cut. Because of SB Three Two Six, our programs be cut, it will have a negative impact on our participants as well as our community.

SB 326 having to force counties to cut existing voluntary outpatient programs and recovery out oriented service that help people stay out of hospitals, out of jails, and off the street. It also will eliminate funding for PEI prevention services, which include peer support services, family education services, and wellness center. I'm here today to oppose SB. Three, two, six. Thank you.

Thank you. Good afternoon. My name is Gordon Reed. I'm the chairperson of Peers Organizing Community Change under Alameda county has over 1600 Members and we say no to SB 326. Thank you. Thank you.

Good afternoon. My name is Damon Shuja Johnson. I'm the Executive Director of Black Men Speak Alameda County. We are peer speaking organization. And with the imposing of 326, we take sides with the ACLU, Camp Row and other organizations. We're returning family Members. And with this thing, it leaves us out of the loop, especially as the African American community and black men coming home from prison. It's not considered. Please pump your brakes. Slow down for us. Thank you.

Thank you.

My name is LaTanya Ri'Chard. I am co founder and associate Director of Communities Voices in Merced County, a small county which is only 3% African American. My question is, if you guys care about us and want peers, why aren't there more peers here on the panels? Why aren't there more black people? You, Mr. Arambla, are from Fresno County, correct? I'm in Merced County. We both know rural counties. Where's the funding? You're cutting funding for us. It's horrible and wrong. I see a lot of you.

You have a courage voting score of F. Many of you have an F courage voting, except for Mr. McCarty. He has an A. Rest of you. And why should we believe any of you when you have a courage voting rate of F? I mean, I know a C student can become President, but why should we care about you guys when you don't obviously care about us? Please don't get me started, because I am livid. This Bill is horrible. Pump the brakes. What is the rush? What's the rush? Why can't you wait until November and consider us? Thank you.

Thank you.

Paul Simmons, with the Depression and Bipolar Support Alliance. I'm going to try not to get into the weeds too much. I'm going to hit a couple of points. First, we've been talking a lot about data and getting the data analyzed, and the peer community has always wanted more data and more analysis. But let's do it before we revamp the entire system. Let's know what the heck we're doing. Second, oversight. If oversight is not independent by definition, it is not oversight. So do not hamstring the MHSA.

I'd like to address housing with housing funding and not taking it away from mental health resources. Absolutely support the increasing of the MHA funding to 1.25 or 1.3% so that we can do it all. Let's not hurt other people. I really appreciate the work that's being done to create more housing. We talk about prevention efforts, but kids don't come out of the womb with schizophrenia. We need to address the societal issues and the social contagion issues that are causing the proliferation of some of these behavioral health issues.

Thank you.

Thank you.

Priscilla Kiros here on behalf of the California Academy of Child and Adolescent Psychiatry. We just want to align our comments with Lishaun Francis from Children Now. I want to thank the Administration, but still have concerns and want to ensure that this measure does set aside a minimum percentage for addressing homeless youth. But also on behalf of the Board of Supervisors of Kern County and Nevada County Board of Supervisors, also expressing concerns with this measure. Thank you.

Thank you.

Good afternoon, chair and Members. I'll keep it short. Izzy Swindler on behalf of Mayor London breed of San Francisco, as well as the City and county of San Francisco. I'm in support of this measure. Thank you.

Thank you.

Good afternoon. Susan Gallagher, Executive Director of Cal Voices. We're the oldest peer run advocacy organization in California, and I want to talk about equity because everyone keeps using it like a buzzword, but nobody really, you don't demonstrate it because if you were to demonstrate equity, clients would have been consulted. Behavioral health clients. Who are most impacted by these choices that you guys are making. We have not been brought to the table. I don't see a panel of us.

So I align my comments with Leslie Napper, Caleche, LaTanya. You can't say what you think is best for us. You have to ask us what person with schizophrenia has been brought up here and said what would work for them? What person who's unhoused has been brought up here and say what would work for you to engage with services? You guys keep making systems that we don't engage in because they're racist, they lack equity, they are not client driven.

And so everything that we're talking about today perpetuates this. I hardly think I had enough time as so many other people, but thank you.

Tiffany Elliott, program manager with Painted Brain. I really implore you to bring stakeholders to the table and not just people who will agree with you, people who have the lived experience that is going to be impacted by these measures, people who have already seen their lives impacted by the conditions that we're discussing. It's imperative. Nothing about us without us.

We need to have a voice. And you're going to find better solutions that are going to work better with the money that we have if you invite us to the table. Please. Please do that. And please, there's no rush on this. We don't need to have all the answers tomorrow. It's okay to take a little more time if that's going to make it better.

If we have this go through in November, we can make something better if we have all the people who are going to be impacted these ways at the table. Thank you.

Thank you.

Hello. My name is Richard Gallow. I'm from Santa Cruz County. I oppose SB 326. This is a one sided initiative. Basically, the peer community was not involved, was not invited. State agencies saying that they're being transformative, collaborative, but they are not. They're excluding us. And that includes the oversight commission. Two things that the oversight commissions have failed to meet the needs of the SMI community, the unhoused community, which that was the intent of the act, to help our communities throughout California.

Secondly, the Oversight Commission have failed to create peer programs, peer services to serve our populations that we work with, with all populations throughout California. They turn on deaf ears. Yes, the Oversight Commission needs to be changed.

Thank you.

So I oppose this. The state is taking the wrong approach.

Thank you. I would note we're at 22 minutes. We've got eight minutes left. We were pretty clear from the beginning, so we have eight minutes left.

My name is Faith Cox. I'm a consumer from Amador County, and I oppose.

My name is Katrina Ozier. I am a program manager for Cal Voices at a program in Amador County or local Wellness Center, and I oppose SB 326. Nothing about us without us. You need to have consumers and stakeholders at the table when you have these discussions. Thank you.

Thank you.

My name is Lorraine Carterrell, and I am a consumer of the wellness centers that have saved my life. Without them, we would be nothing. I'm opposed to SB 326.

Okay, thank you.

Good afternoon. I'm Portia Lee of Oakland, California, Alameda County. I work with peers, envisioning and engaging in recovery services. I was also once a participant of these PEI programs, and these services, they have helped me in my recovery. They have allowed me to keep my family together, and I oppose.

Thank you.

Good afternoon. I'm Sarah Markshire from Alameda County. I oppose SB 326. I have lived experience receiving MHSA funded services, and I work for one of the many peer run, recovery oriented programs that do serve people most in need already, including people who have experienced multiple hospitalizations, have experienced homelessness, and have experienced incarceration. And our programs are threatened with being defunded under SB 326. Thank you.

Okay, thank you.

Hi. Good afternoon. My name is Claire. I'm a peer, and there's many things I could say, but I think the most important thing is that the MHSA saved my life. I was a person who was sick for ten plus years. Not in any kind of services, not signed up for Medical, and I had a peer support worker provide me services for the three months it took, sign me up for medical, give me services every day for five months, and that's special.

And Medi Cal will never replicate that. That is an actuary at an insurance company deciding what I need, when, and how much. This was a no barrier, no money, perfect service for me, and it absolutely changed the course of my life. So I just want to say, maybe these funding allocation buckets are fungible, but people are not fungible. And when you are talking about cutting 65% of outpatient services in this county, that is catastrophic.

And I'll just be real because there's been so much courage before me. Nobody really wants this. The counties don't want it. The clients don't want it. Thank you.

Good afternoon. My name is Indira Infante. I'm here with my lived experience. I am a parent of a child who's received MHSA services. I'm also a program manager at the Children's System of Care through my agency, Cal Voices, who receives our funding streams from MHSA, who has benefited numerous hundreds and hundreds and hundreds of families yearly. We do have the data to prove it as well.

We support immigrant children, children who do not qualify for any other services, families that do not qualify for Medi Cal. I completely and utterly oppose this Bill. I'm hoping that you guys will reconsider and start figuring out different ways of obtaining the funds that you need for housing, because we definitely need those as well. They underserved the people that nobody thinks about. And I forgot which one of you asked about landlords. Landlords don't rent to people that don't have rental history or are of low income services. We have a lot of underserved people in all of these counties. I come from Placer where we do have tons of resources, but there's still an extreme homeless.

Thank you.

Okay, thank you. Thank you. Sorry. Yeah, but I'm blind without my glasses, so I didn't see the time. I apologize. Thank you. Thank you.

Richardson Davis from the California Community Council of Behavioral Health Agencies. I just want to align my comments with Dr. Leandro Clark Harvey at the recent Senate Informational hearing, and we recently submitted a letter with our concerns and look forward to working with you all. Thank you.

Thank you.