Assembly Budget Subcommittee No. 1 on Health and Human Services

Good afternoon. This is the Assembly Budget Subcommittee Number 1 on Health and Human Services. Today's hearing is focused on seniors and on health equity. In addition, we will have a special order of business at 05:00 p.m. today to hear the Governor's mental health modernization proposal. Given the length of today's agenda, I would like to request that all our speakers be as brief as possible. We will have panel presentations on the first 19 issues on today's agenda, while the remaining 20 are non-presentation items.

Since we have a special order of business at 05:00 p.m. for the mental health modernization proposal, we will begin issue number 15 at 05:00 p.m. even if we have not yet finished with the first 14 issues on the agenda. We will then finish the prior issues on the agenda after issue 19 in this case.

Members are welcome to ask questions on all issues in the agenda, including on non-presentation items, and we welcome public comment on them at the end of the hearing, should there be any. We are located today in Room 437 in our State Capitol. With that, we will begin. Let us have our first panel with Dr. Radhakrishna. Please come forward.

Good afternoon Chair Arambula and all Members of the Assembly Subcommittee. My name is Dr. Rohan Radhakrishna. I have the honor of serving as the Chief Equity Officer at the California Department of Public Health, where I lead the Office of Health Equity, and I'm here also on behalf of our Cal Health and Human Services Agency. I'll provide a brief overview and answer the three questions provided by the staff, if that's all right.

So issue number one, this budget item is a technical transfer of one position from our agency to our department. With this item, the Office of Health Equity that I lead will hire a position and take lead on coordinating the retrospective analysis on equity from COVID-19 with internal and external stakeholders, including but not limited to, local government, academia, other states and national entities, and community-based groups.

We already have live dashboards from an equity lens showing the relationships between COVID outcomes and certain social drivers of health like income, crowded housing, and access to health insurance. And we have already released an early report in July of 2022 that my office commissioned focused on supporting communities and local public health departments during COVID-19 and beyond. It's titled 'A Roadmap for Equitable and Transformative Change'. It encompasses the first year of the pandemic, but it is not a retrospective analysis.

Nevertheless, the 208 page report does have very many relevant chapters and recommendations. We haven't yet completed a retrospective analysis because the pandemic lasted longer than we all imagined back in 2021 when this item was originally crafted. CalHHS and CDPH have been actively in response mode for the past three years. Coming from a local health department in the middle of the pandemic to join state service personally, I'm familiar with both levels and perspectives. COVID is still with us.

It's not yet fully in the rear view mirror. Hence, a retrospective equity analysis has not yet been completed. Just like no after action reports have been completed, the proposed retrospective analysis will look at the intersection of the COVID-19 pandemic and the health disparities and inequities that were further perpetuated due to the pandemic. The purpose of this analysis, as articulated on page 10, is to better understand how these underlying disparities and inequities fueled the pandemic and what can be done to prepare for future crises.

How we bounce forward as opposed to going back I'll now answer the three questions proposed by staff. First, the timeline for this analysis. If this budget change proposal is accepted, we will transfer the position from agency to our department to hire this lead coordinator this summer, who will begin work with many internal and external partners conducting after action reviews. Preliminary mapping has already begun and will continue throughout 2023. We anticipate completing the analysis in 2024 or 25. Question two, how will CDPH share the final analysis?

We plan to post it publicly on our website for consumption by all. And question number three from Assemblymember Calderon with a letter proposing an amendment. In response to this letter, I would like to exclaim the importance of the issue and appreciate what Assemblymember Calderon raised in their letter regarding the economic impact of long COVID on women. We are happy to share our current and ongoing work related to long COVID with this Committee and directly with Assemblymember Calderon.

While CDPH's Center for Infectious Disease has created a COVID-19 control branch to continue working on the impacts of COVID, including long COVID, it is and will continue examining the impact of long COVID on Californians. However, a specific economic impact on long COVID on women is beyond the scope and expertise of the much broader equity retrospective analysis and this budget change proposal, which is a minor technical transfer of one AGP staff from the family of the agency to our department.

Conducting a true economic impact would require additional funding and a health economist. I'll briefly summarize what we are doing in regards to long COVID. CDPH is engaged in multiple activities to assess, communicate, and coordinate around long COVID in California. These efforts include collaborating with federal and academic partners to assess incidents, risk factors, measuring burden in the state using different survey tools, developing communication materials for patients and providers, and facilitating interagency coordination for post-COVID public health action.

Through these efforts, CDPH aims to characterize the proportion of COVID-19 patients that have ongoing health effects, the duration, the severity of those effects, and patients at greatest risk, including characterizing the burden based on different demographic disparities, including gender and women. The hope is that this data will inform public health programming to assist Californians most impacted by long COVID. Furthermore, I'll guide you to CDPH's occupational health branch, which already has live on its website information on long COVID and workers, employees in the workforce.

This includes tools for workers and accommodations for employees under the Americans with Disability Act. So as mentioned, we're happy to share current and ongoing work related to long COVID with Assemblymember Calderon. Thank you.

LAO.

Will Owens, LAO. We have no concerns with this proposal.

Department of Finance

Nick Mills, Department of Finance. Nothing further to add, but available to answer questions.

Bring it up to the dais for any Members' questions. We'll begin with Dr. Jackson.

Thank you very much, Mr. Chair. This item is actually very important that we do a thorough recap on our strengths and weaknesses that we've encountered, how we have- Before I came here, I was on Riverside County's Equity Task Force for COVID-19 and one of the greatest things that I think now informs my work is that efficient doesn't mean the best choice. And because we start to do the most efficient things, we began to create disparities, right?

Which means we had to then engage more community based organizations to truly achieve equity in the distribution of resources, whether it's PPE, whether it's being able to educate people on the vaccine and those type of things. The only thing that I would request in this item, Mr. Chair, is that we also include some level of recommendations to the Legislature. There are things that we proven that we could do that are now sunsetting, but we're hearing throughout the systems that those are still good to have.

And because there's so many of them that were created that are now sunsetting, it would be great for the Legislature to be able to relook at those so that we can make sure that we are prepared for the next pandemic, the next whatever, that might lend these type of things to us.

So even though it's great that it'll be for the public to see, I would like to make sure if we are going to be approving this, that we get some stuff out of it from a more practical things of how we can better do our job in preparing for the next thing. My greatest fear is that which is already happening. We're moving on to the next thing, right? And we still haven't fixed some of the opportunities.

I see a SWOT analysis in here, so I'll just say opportunities to be able to fill in some gaps that still exist, right. That we saw were some of our weaknesses in our society. And I want to make sure that we can continue to do that work. And this document could actually help us to do it more efficiently or effectively. Thank you.

Thank you. I'll bring it to the Chair if I can. I was really drawn to your comments about what fueled the pandemic, and oftentimes it was those social drivers of health you spoke about income, crowded housing and access to health care that I'd also like to understand the role that CalAIM will play as we are rebounding out of this pandemic and the supportive services or enhanced case management.

It would be important with this position that those recommendations allowed us to see how we could impact those social drivers of health beyond the three that you listed, but would love to get more clarity as you dig into it and do your analysis. Wanted to give you an opportunity to provide some comments.

Yeah, thank you. First, Dr. Jackson, thanks for your work in Riverside. They were one of 68 key informants that went into our preliminary report, and it does have policy recommendations for different levels of jurisdiction. Some have been implemented, some are opportunities for the long term. So we'll keep that in mind. And to directly answer your question, Dr. Arambula, we will continue to coordinate with the Department of Healthcare Services and their CalAIM initiative.

They have an equity roadmap which will be presented in June at the Quarterly Office of Health Equity Public Advisory Committee. So we have a 26 member advisory board, and we tackle different topics. And by statute, we work and partner with Department of Healthcare Services. They have a new chief equity officer as well. So we'll definitely reach out to them, as well as many Cal OES, local jurisdictions, others within our agency family in conducting this retrospective analysis absolutely.

It's identifying those drivers that will allow us to focus our limited resources on providing solutions in real time. And so we're grateful that you're doing this retrospective analysis, but we have to look at some of the lessons that we learned during this pandemic of the century and to figure out how to do it better. And I believe it's important for us to do this work.

We're supportive of the BCP, but for many of us, it's just taken so long to get to the place where we're at now that we don't accept the results that happened during the pandemic and are looking forward to the opportunity to create a system that doesn't have the disparities that we see within it. With that, we will thank very much this panel and move on to issue two.

Good afternoon. Nick Mills, Department of Finance. The budget reduces $25 million General Fund-

I think we have a climate change and health equity section chief from CDPH who is joining us remotely.

Yes.

Afternoon. This is Linda Helland with the Office of Health Equity, Climate Change and Health Equity Section. I will defer to the Department of Finance to present the issue and cover questions brief.

Here we go. All right. The budget reduces $25 million General Fund in 22-23 for climate and health resilience planning grants. If there's sufficient General Fund in January 2024, this reduction will be restored. This reduction is consistent with the administration's overall approach to addressing the budgetary problem through delays or reductions of some spending in the near term. Where feasible, the budget prioritizes ongoing commitments included in previous budgets and climate health.

That includes 10 million General Fund ongoing for DPH's Climate and Health Surveillance Program to provide near real time notification for Public Health Department's first responders in the community for emerging climate sensitive diseases. I'll now answer question number three in the agenda regarding the trigger, and then we'll turn it over to the Department for the other two questions. The potential restoration of this proposal, which is contingent upon certain General Fund revenue criteria being met, is operationalized in control Section 3.94 in the Governor's Budget in AB 221.

This control section identifies that on or before January 10, 2024, the Director of Finance shall determine whether the state has excess General Fund for the 2024-25 fiscal year that is sufficient to support the restoration of all the reversions and reductions identified in the section. And excess General Fund is defined to be the total General Fund available for allocation if the state fully funds baseline obligations, enrollment, caseload and population adjustments, as determined by the Department of Finance at the release of the Governor's Budget for fiscal year 24-25 plus various constitutional obligations such as Prop 98, the Budget Stabilization Account, and the public school system Stabilization Account.

If there is sufficient General Fund revenue, Finance will notify the Joint Legislative Budget Committee of this determination and will provide the controller with a schedule of appropriations in fiscal year 23-24 to be augmented through an Executive Order, and I'll turn it over to the Department for the other two questions.

Thanks. Good afternoon, Chair Arambula, Assembly Members. I'm Linda Helland with the Office of Health Equity in California Department of Public Health. I will address the first and second questions. How did CDPH plan to distribute these funds? 25 million? And was this intended to be a grant program for local health jurisdictions and tribal health programs? I will answer question two first. Yes, this was intended to be a grant program for local health departments, tribes and community-based organizations to develop climate and health resilience plans.

Of the total award of 22.5 million after Administration and staffing costs, 1 million was planned for consultants, leaving 21.5 million for local assistants. Of that, 64%, or 13.8 million, was planned to be for local health departments, and about 18% of that, or 3.85 million for community-based organizations, and similarly about 18% or 3.85 million for tribes.

And because competitive grants tend to be inherently inequitable, as the most resourced jurisdictions with the most money for consultants and grant writers, or the most free time to write good grant applications tend to be rewarded with further funding. We wanted to allocate the funding to an equity framework to local health departments and tribes, and we're in the process of engagement with them when instructed to stop work on this program in December.

And for CBOs, we would likely have had to release a competitive solicitation, but wanted the application to be fairly simple and make awards based on demonstration of need. I will stop there and take questions or comments.

LAO.

Will Owens, LAO. Given the state's current budget situation, we generally find that this solution meets some of the criteria that we had laid out earlier in the year on solutions that would disrupt services, be fairly recent, and so we have no concerns with the pros at this time.

Bring it up to the dais for any Members' questions. Seeing none, I'll keep it here at the chair. First, I was struck. We've both had it described that this is the most significant public health threat that we face today. Then I'd like to understand how we can explain when only a couple of our local health departments are making significant investments regarding this issue. Should we be expecting more given the greater investments that we've done to local health departments, the 200 million ongoing that we gave them last year? What is our expectation?

Would you like me to try to answer that?

Please.

Some local health departments are using some of those 200 million to address climate change. A few of them have proposed and actually are addressing the health impacts of climate change through their future of public health or California Public Health Initiative funding. Previous to that, there were about four funded health departments through their own funding or through CDC Climate Health Program funding. This would have been the first dedicated state funding to local health departments to address this issue.

Department of Finance

Sonal Patel, Department of Finance. I would just like to add that although this is one reduction contained in the Climate Health investment, the budget does maintain 321 million to continue other investments such as, as my colleague noted, the 10 million ongoing for surveillance as well as an additional I apologize, approximately 280 million for community health workers, some of which will be engaged in climate health work.

We'll just state this is not inherently regarding the reversion or the restoration, but a commentary on the lack of investments that have been occurring from our local health departments. The agenda highlights that there's only two departments that currently have full time staff dedicated to addressing the health impacts of climate change and knowing that these impacts disproportionately affect our communities of color, it's imperative that our local health departments are working to come up with solutions that meet the needs of all of our communities.

And hence why we're asking. I'll follow up if I can. The agenda also mentions the disproportionate impact that occurs for many of our tribal nations and how they are not given significant access to governmental planning efforts. That I want to kind of understand, are our tribal nations represented on our air quality management districts as an example? Should they be?

Their borders lie within air basins, but their sovereign nations also require an opportunity to have a seat on those decision making that I'd like to understand. Are we planning to start to work on that to make sure that they have a seat at the table? That's for the Department, if you can.

Address tribal nations seats on air quality management districts? I think that is unfortunately a question that I cannot answer, not being in charge of air quality management districts. But I will tell you that we do have one staff person working on a dedicated basis with tribes to support them to address the health and equity impacts of climate change on the tribes. And they are definitely working very hard in facing those impacts on a daily basis and want to do more.

And so we are supporting them to the extent we can with technical assistance and data and tools with one staff person.

There will be more conversations about some potential ways to be inclusive and to make sure that all voices are able to be heard, but we'll come back to that at a later time. I will briefly bring up issue number 34, which is currently on the non presentation item, but has a correlation here as it's related to extreme heat and the AB 2238 BCP. Since we won't be discussing it later, I'm really trying to understand the extreme heat ranking system and ways in which it will be coordinated.

Happy to follow up offline if you don't have any answers today, but there was a delegation that went to France to learn from that country about extreme heat and their warning system that I'd like to be able to work with the Department and understand if there are lessons that we can bring over from that country, as well as whether or not there are other examples within our current government, such as PSPSs, the public safety power shutoffs, the notifications that we're doing for our elderly population when we're going to turn power off, that I'd like to understand how you're going to be implementing this, and I would like to be able to work with you going forward.

Should I answer that, or would you like me to answer that at a different time?

You can follow up with our office, if that's okay. I will thank very much this entire panel, and we will now move on to issue three.

We will begin with Ms. Ochoa when you are ready.

Okay. Good afternoon. Maria Ochoa, one of the Assistant Deputy Directors within the Center for Healthy Communities in CDPH. And today I'll be providing a brief overview of one of our spring finance letters for protect protecting children from the damaging effects of lead exposure. So lead is one of the most common environmental illnesses in California. Lead can have harmful effects on a child's body, which may lead to lifelong learning, behavioral, reproductive, cardiovascular, and other health problems.

Within CDPH, the Childhood Lead Prevention Branch leads these efforts and is supported by fees assessed and collect annually from lead polluters. Most of the funds are distributed to 48 local health jurisdictions that conduct lead poisoning prevention and basic case management.

CDPH is requesting two positions and 9.7 million from the Childhood Lead Poisoning Prevention Fund in fiscal year 2023 through 2026, and 6.1 million ongoing for additional case management activities that have increased as a result of the 2021 Center for Disease Control and Prevention updated blood lead reference value from five deciliters to 3.5 and to also address the finding of a 2019 audit by the California State Auditor that recommends CDPH's CLPPP program to focus more on primary prevention of childhood lead poisoning.

Of the 9.7 million, 5.9 will be allocated for basic case management services to be performed by state and local staff. 3.6 will be allocated to develop and enhance local general prevention measures outlined in the 2023 through 2026 scope of work proposed by contracted LHJs. 214,000 will be allocated in state operations to establish two positions to provide direct services provided by state and local public health nurses, community care workers, and environmental professionals that perform case management, care coordination, and environmental investigations to identify and remove lead sources.

And there were a couple of questions within the agenda. So the first one was, does CDPH have authority to increase the fees as necessary to cover the increasing cost of the program? CDPH has the authority to increase the Childhood Lead Poisoning Prevention fees for program costs in Health and Safety Code 105310G, which sets a fee cap adjusted for inflation, pursuant to Subdivision B. CDPH will continue to monitor expenditures and revenue projections and plan for fee adjustments as necessary.

And the second question was, does CDPH have any way to measure outcomes in order to evaluate the effectiveness of the program? And yes, CDPH continually measures effectiveness and program outcomes through surveillance data, site visits, and progress report trackers. These measures occur at both the state and local level. CDPH posts data annually and reports biannually, which provides information on the rates of childhood lead poisoning, effects to increase screening, and efforts to reduce prevalence of childhood lead poisoning. This BCP is in response to CDPH's past work measuring the effectiveness of this program and has the goal of increasing screening rates and primary prevention. Thank you.

Next we will hear from Ms. Gibbons, Executive Director of CHEAC.

Thank you. Good afternoon, Chair and Members. My name is Michelle Gibbons. I'm with the County Health Executives Association of California, representing local health departments throughout the state. We're supportive of the Administration's request for additional funding for the California Lead Prevention program. I'm just going to refer to it as CLPPP. However, we believe that local health departments will need additional funding beyond what has been requested to fulfill the requirements of the scope of work relative to the next three years.

Local health departments contract with CDPH to administer various aspects of the CLPPP program. The program originally required local health departments to provide provider education and case management for children with elevated blood lead levels, which were previously valued at five micrograms per deciliter, and then to remediate the sources of lead for those children that were being case managed. The new scope of work increases the workload for local health departments in two ways.

First, it lowers the blood lead level reference value to 3.5 versus the 5 to align with the Centers for Disease Control and Prevention. This results in increased numbers of children requiring case management, and it results in a longer duration for case management because you have to get kids down to below the 3.5 level now. The scope of work also adds new primary prevention activities that includes roughly 100 tasks, or up to 100 tasks, that local health departments are responsible for completing.

Many of those tasks are entirely new requirements for local health departments. It's unclear to us how the state estimated the FTEs and salaries needed to complete this work, given local health departments do not report in that manner. To better understand what the actual costs were with implementing these new requirements, CHEAC began to outreach to our members.

While this process is still underway, we know that with just 11 jurisdictions, ranging from very large to small counties, they need roughly 19 million to fully implement the scope of work requirements. The current allocation for those same jurisdictions is roughly 7.6 million. We're concerned that locals will have increased responsibilities without sufficient funding to carry out those duties, and in that case, CDPH should expect locals to respond to the scope of work identifying what work they can carry out with the limited funding, but not all.

We hope we can work with the Administration and Legislature to fine tune the funding request to support local health departments in carrying out both case management and primary prevention. And I would just note that there is a fund balance, however, if fully funding local health jurisdictions would exceed the fund balance, then we would recommend increasing the fee to compensate for that. Thank you for the opportunity to provide remarks, and I'm happy to answer questions when appropriate.

Department of Finance.

Nick Mills, Department of Finance. Nothing further to add, but available to answer questions.

LAO.

Will Owens, LAO. We have no comments at this time.

Bring it up to the dais for any Members' questions. I'll keep it here just for a second. I want to give the Administration a chance to respond to CHEAC. It seems that with the decrease from 5 to 3.5 that there's significant increase in workload, both for primary prevention and for case management. And in light of the request, doesn't it make sense for us to consider those fees and to evaluate, since you have the statutory authority?

We do continue to assess this annually, and we are committed to working with CHEAC and have their concerns and building that partnership.

Well, the sooner you do it, the better, as there's no amount of lead that's safe for our children. And I'm appreciative that we're moving in the right direction. But it then requires us to be staffing and providing the resources to address the issue head on. So would encourage you to get there as quickly as you can. With that, I will thank very much panel three and move on to issue four. Issue four is on EMSA's diversity, equity, and Inclusion Strategic Plan Development, BCP. We will begin with Kim Lew, who is the Chief of Personnel for EMSA. Please begin when you are ready.

Good afternoon. Thank you for the invitation to come and speak with you today. My name is Kim Lew. I am the EMS Authority, known as EMSA's, Division Chief over the EMS Personnel Division. To the left of me is Rick Trussell. He is our Division Chief over our Administration Division. As requested, I am here to present the diversity, equity, and Inclusion Strategic Plan development budget proposal currently under consideration, and we'll also respond to any questions raised at the end of my presentation.

Diversity, equity, and inclusion is something that we have not had much of an opportunity to look into within our department. As such, we are asking, through this proposal, we're requesting $100,000 in General Fund for the 2023-24 year to contract with a consultant to assist in the development of a diversity, equity, and inclusion strategic plan that aligns with the California Health and Human Services Initiatives that you had heard earlier today.

This will help to reduce health inequities and disparities and to support the EMS Authority's strategic priorities. As we've heard, health equity has been a key focus of the Administration, and the COVID-19 pandemic has accelerated that need for additional action. It is critical that Californians of all ages, abilities, and backgrounds have equitable access to the conditions that optimize their health. This would include prehospital EMS. This is especially critical for communities that have experienced socioeconomic disadvantages, historical injustices, and other avoidable systemic inequities.

To do this, the EMS Authority must coordinate with CalHHS so that its policies and programs are strategically aligned to further statewide equity goals. CalHHS's guiding principles include a focus on equity and emphasis that must support CalHHS as a leader in the fight for equity and strive to create programs that address persistent and systematic inequities to create a state where citizens can have the opportunity to thrive.

This also includes removing, first of all, identifying and removing barriers that impede certain groups and individuals from achieving optimum health and wellness because of the color of their skin, gender identity, sexual orientation, age, or disability. Health equity workforce diversity and inclusion are critical elements of this mission and have long standing barriers to health and wellness of the diverse population throughout California.

By approving this request, it will allow the EMS Authority to continue to support its missions and its goals, improve the sustainability of pre hospital EMS equity and social justice efforts within the state, local, private, and community based organizations. It will help to improve EMS patient outcomes in disadvantaged and disparate communities across the state. It also aligns with CalHHS's mission of creating patient focused programs addressing access, treatment, and work stream to combat EMS healthcare disparities and workforce initiatives in inequality.

Some of this money will go towards the EMS Authority, maximizing community partnerships and stakeholder collaborations. We will incorporate health equity concepts and measures into the EMS Authority's programs and policies. We will conduct a SWOT strength, weakness, opportunities, and threats analysis in helping to plan for our future initiatives. We will also include a vision, objective, strategic goals and tasks along with action items using key performance indicators and baseline metrics. We want to develop mechanisms to collect detailed EMS personnel workforce data as well.

We have identified that there is some disparities and some concerns among our population in just even being comfortable having EMS personnel come out, particularly if they don't look like or speak like what they're used to in their own families and businesses. So we'd like to invest some of this funding into looking at the workforce and including the diversity there as well.

We also want to secure training and host forums for EMSA staff and our partners and create a workforce to assess the impact of EMS workforce and cultural competency training for those EMS personnel on patient health outcomes. And then we will also conduct metrics and performance indicators to determine how that might look and what we might want to establish as benchmarks moving forward. So this is a preliminary effort to do an assessment of our Department and the services that we provide through the workforce and with patient outcomes. Thank you.

Mr. Trussell.

I have no comment. Thank you.

Department of Finance.

Shelina Noorali. Department of Finance. Nothing further to add.

LAO.

Will Owens, LAO. We have no concerns with this proposal.

Bring it up to the dais. Dr. Jackson.

Thank you very much for this item. Obviously very important, and thank you for being proactive in doing so. My only question is in regards to the rich diversity that exists in California, right. Of course, if I'm an EMS worker, and I'm in the San Jose area, totally different population and cultures that come with that.

Like, if you're trying to save lives, you have to understand the cultures of very people different from LA County, different from Coachella, farmworker area, right. How are you going to design it in a way that allows people to really understand that there's still some uniqueness depending on the populations they serve in the different geographic areas of California?

Great question. Thank you. We are a small department, but we understand the impact that this is going to be or could be. So our intention of having a consultant come in is to look at what we should do and to do an assessment across the state, which would include having that consultant, along with some of the staff that I currently have, along with the local EMS agencies and community based organizations, getting together to have that very discussion and what that might look like for our EMS personnel in required training, continuing education, cultural competencies, as well as employers in hiring practices for diverse individuals.

And we want to talk on the other side of that, the community based organizations of those disparate families and the businesses in those communities. So we have to start somewhere, and that's part of this initial assessment. It'll come later down the road once we've identified our deficiencies.

Thank you.

You're welcome.

I will thank very much this panel. We will now move on to issue five.

Thank you.

Thank you.

Issue five is on the Department of Healthcare Services, California Cancer Equity Act, BCP. Lori Walker, the Deputy Director and Chief Financial Officer with DHCS, is going to start when you are ready.

Good afternoon. I'm Lori Walker. I'm the department's Chief Financial Officer. The department's requesting three permanent positions, one LT position, contract, resources, and expenditure authority of approximately $1.1 million. Resources are needed to develop and implement good faith effort contracting requirements for Medi-Cal Managed Care health plans, develop and implement a cancer center referral program for enrollees with a complex cancer diagnosis, develop a process in consultation with appropriate stakeholders to continually update and further define complex cancer diagnosis for purposes of the referral program, and conduct ongoing monitoring and oversight of managed care plans and take corrective action when necessary.

The bill requires managed care plans to make good faith efforts to include at least one National Cancer Institute designated cancer center or qualifying academic cancer center within their contracted and subcontracted provider networks within each county in which they operate for the provision of medically necessary services to members diagnosed with a complex cancer diagnosis.

Eligible members have the right to request referrals to these in-network cancer centers, and in instances where an MCP is unsuccessful in its good faith contracting efforts, members can still request referral to an out of network cancer center. However, the access is limited to when the MCP and the out of network cancer center are able to come to agreement in terms of payment.

The requested resources will work to develop a definition of a complex cancer diagnosis and a stakeholder process for updating and defining the diagnosis on a periodic basis. There's no standard definition of a complex cancer diagnosis at this time, and this would require extensive clinical expertise and a process to come to consistence on such a definition. A subject matter expert is needed to differentiate what should be included in the definition of a complex cancer diagnosis and to conduct ongoing review and maintenance of the list of eligible diagnosis. Currently, DHCS does not have a subject matter expert with an oncology background who can manage the bill's requirements. Happy to take your questions.

Department of Finance.

Andrew Duffy, Finance. Nothing further.

LAO.

Jason Constantouros, LAO. We have not raised concerns with this proposal.

Bring it up to the dais to see if there are any Members' questions. Seeing none, I will thank very much this panel. We will move on to issue six. Issue Six is on the $1 premium subsidy augmentation proposal at Covered California, which will be presented by the Department of Finance. I believe it's Joseph Donaldson.

All right. Good afternoon, Chair, Committee Members. Joseph Donaldson, Department of Finance. Under the Federal Affordable Care Act, federal dollars are not allowed to be used to provide abortion services. When the ACA was passed, plans that covered abortion services would charge consumers a flat premium of no less than $1 per month to not violate federal policy. Because California law mandates all plans to cover abortion services, all consumers were impacted and thus required to pay this $1 monthly premium.

As a result, the 2021 Budget Act included a 20 million General Fund ongoing appropriation for Covered California to make these payments on behalf of individuals in plans through the exchange equal to the cost of these monthly premiums. This program would be called the $1 Premium Subsidy Program. Now, due to increased enrollment, Covered California is requesting an augmentation of 350,000 ongoing to its original appropriation.

The current appropriation is not sufficient to provide the services at this time and this increased expenditure authority will serve an estimated 29,000 additional enrollees. Now, it's important to note that this proposal is for 23-24 and ongoing. However, Department of Finance, in collaboration with Covered California, submitted an approved JLBC letter increasing this appropriation for the current year pursuant to current law. Committee had a question related to this proposal, asking if there is a way to Fund this based on enrollment estimates.

At the time, the Administration does not believe it is necessary to approach the program in this manner, as this program has been fully funded to meet anticipated demand through the budget process. These reproductive health services are and continue to be a high priority, and the Department of Finance has worked with Covered California to stay apprised of any budget needs. Additionally, we have the necessary mechanisms through current law to make adjustments as needed, and as such, approaching the program in this manner would not be needed and happy to answer any questions you may have.

I have Mr. Aguilera, if you have any comments.

No, I have nothing to add.

LAO.

Luke Koushmaro with the Legislative Analyst Office. As the Administration noted, enrollment in Covered California has increased substantially in recent years, and as such, we do find it reasonable to make an augmentation to account for the enrollment trends, such as what the Administration is proposing. However, rather than making an ongoing augmentation of $350,000, the Legislature could consider directing the Administration to adjust their appropriation based on forecasted enrollment. We note that Covered California already does forecasts of their enrollment, and there are similar types of adjustments made in other parts of the budget, including in the Department of Healthcare Services budget and the California Department of Corrections and Rehabilitation.

A population based adjustment would help ensure the program is appropriately funded based on the number of individuals enrolled in Covered California plans in a given year, and we note that over the next few years, enrollment in Covered California plans could fluctuate considerably due to a number of factors, including the end of the continuous coverage requirement in Medi-Cal, which will result in decline in Medi-Cal enrollment and potentially result in an increase in people shifting to Covered California.

In addition, enhanced federal premium subsidies in Covered California are expected to end at the end of calendar year 2025, which could result in a reduction in Covered California enrollment, and there are also potential changes the state may make in terms of financial assistance provided by the state to Covered California enrollees. So doing an adjustment based off of enrollment could ensure that the amount of funding available remains appropriate for the population to address these issues. Thank you.

Thank you. I'll bring it up to the dais for any Members' questions. I'll keep it here at the Chair, first. I just want to state how supportive I am of the proposal overall, but would like to follow up on what the LAO is commenting regarding enrollment trends and why we aren't doing population based adjustments as we do within other DHCS programs.

Your answer earlier was you don't believe it's needed, but shouldn't we base it on population, so we can get adequate projections, so we can build the budget out? Or why are we not looking at number of people served and are simply looking at a flat number?

Matt Aguilera for Finance. You know, there are several entitlements in the state. As you know, there's also other programs that are just funded subject to the funds provided, and I think, in this case, it falls under the latter category. However, many of those programs are treated like an entitlement in that as their enrollment changes through our normal budget process, we're addressing that through our normal budget process. So that's the way we've been handling this program.

If it's not an entitlement, doesn't that then mean we're only covering it for some people? And haven't we been pretty clear about who we are as a State of California in ensuring that all who wish to access reproductive services are going to be given that opportunity? So it seems contrary to me a bit and really would like to evaluate these population based adjustments as a way to ensure that we're right sizing the proposal going forward.

With that, I will thank very much this panel and we will move on to issue seven. Issue seven is CDPH's facilitating projects to benefit nursing home residents, BCP. We will have Michelle Bell, Office of Internal Operations Chief in the Center for Healthcare Quality at CDPH, who will begin.

Hello there. I also have... Can you hear me okay? I also have Chelsea Driscoll, our Public Policy and Prevention Division Chief, with me today. Okay, much better. CHCQ is requesting an increase in local assistance expenditure authority of 5 million in 23-24, 5 million in 24-25, and 3 million in 25-26 for the Federal Health Facility Citation Penalties Account. CDPH also requests provisional language to extend the expenditure and encumbrance authority through June 30, 2027. Civil Money Penalty, or CMP funds, are penalties that are collected from nursing homes that are not in compliance with federal regulations. These funds are reinvested to support CMS approved projects that protect or improve the quality of life of nursing home residents. These funds will allow CDPH to execute contracts for current and multi-year projects in a timely manner.

Is that the conclusion of your Department of Finance?

Nick Mills, Department of Finance. Nothing further to add.

LAO, Will Owens, LAO, we have no concerns with this proposal.

I'll bring it up to the dais to see if there's any members'questions. I will just uplift how important it is to have person centered care. One of the examples that came from this was life BIoS, which took time to tell the life stories of nursing home residents so that those who are working at the nursing home understood a little bit more about them. Seeing them and listening to their stories, I think, is a very important investment, and I'm grateful that the Administration has this proposal. With that, I will thank very much this panel, and we will move on to issue 8.

Issue 8 is the Internal Department Quality Improvement Account Provisional language proposal. Miss Bell, when you are ready for.

Any potential projects that may exceed the existing Account Expenditure Authority, CDPH is requesting provisional language be included in the Budget Act. That allows us to request from DOF the ability to increase that expenditure authority from the account after reviewing a request that we submit demonstrating need for that additional authority. This language, while new, will allow CHDQ to identify quality improvement activities that we'd like to Fund through this account and to request expenditure authority in the current year.

Department of Finance. Nick MIlls, Department of Finance. Nothing further to add. LAO

Will Owens, Lao. We haven't raised concerns with the proposal at this time.

Bring it up to the dais. Dr. Jackson,

What would you usually do if you needed to make a change? Would this be a budget change proposal?

Correct. And our concern with that would be it would create unnecessary delays in the process. We've been making a lot of investments in terms of our program's technology and efficiency in recent years, and we do have projects on the horizon, but as of this point, they weren't necessarily far enough along in the PAl process to request funds at this time.

Okay. Can you give me an example of what would make something urgent that would necessitate something faster than a budget change proposal? Is there something like, I'm a new kid here, so you're going to have to help me visualize it?

Yeah, absolutely. So we certainly would submit a budget change proposal for a major technology enhancement. So, for example, we're hoping to procure an online application system for all of our applications, but particularly for smaller projects.

Let's see. One that we might have coming up is we're looking to procure a way for us to securely get investigation documents from healthcare facilities and to reduce our staff's reliance on paper, things like that. They're small. They might not necessarily. It helps us to have some flexibility there.

I'm always for flexibility. I'm just concerned that this is a little bit too broad and not specific. Meaning, at what dollar number would you request a BCP. Right. Like, there's no ceiling here when it comes to. And even though one project may be little, what if there's multiple things that need to happen? Right.

So we might just need to tighten up the language a little bit to making sure that we're not just doing a blank check kind of thing, but certainly want to find that sweet spot for flexibility, but yet making sure that we're doing our job in terms of accountability as well. Thank you, Mr. Chair.

Dr. Wood. Thank you, Mr. Chair. Did I hear you say that complaints are being filed on paper?

Still no. So we've used these funds to implement, in past years an online system that allows our staff to do complaint investigations. But not all of the elements of the process are fully electronic. So, for example, we still have health facilities that may want to hand us paper as part of an investigation. And what I was referring to was the need to have a secure, electronic way to collect documents such as that.

Okay, thank you. I'm sorry. With it, I will share the concerns of Dr. Jackson and look forward to the discussions as we move forward. We will. Thank very much, panel eight, and move on to issue nine. Issue Nine is a proposed trailer Bill on the removal of the Federal Health Facilities Citation Penalties Account Award limit. We will begin with Miss Bell.

Okay, so, in 2007, AB 1397 created separate penalty accounts for state and federal civil penalties and established a $130,000 annual cap on the amount of money from the FHFCP account that CDPH may spend each year per project. This amount has not increased in the 15 years since that bill's passage. This limit conflicts with the mandate that we have from CMS to spend down the balance of this Fund on projects that improve the lives of nursing home residents.

Although CMS does prohibit costs that appear excessive or unreasonable, CMS does not specify a ceiling amount for these projects. Additionally, CMS has already approved multiple projects that exceed the current limit. This proposal would align state law with federal guidelines. At the end of fiscal year 2122 the balance of this account was approximately 13.9 million. And in consultation with CMS, CDPH always keeps a two to $3 million Fund Reserve in the event of unanticipated expenditures or additional funding for temporary managers, patient relocation expenses, et cetera.

Removing the spending cap is necessary to allow CDPH to Fund a sufficient number of projects, thereby improving the lives of long term care facility residents and satisfying CMS's guidance regarding spending down these penalty funds.

Department of Finance Nick Mills Department of Finance nothing further to add.

LAO, Will Owen LAO, we have no concerns with this proposal.

Bring it up to the dais for any Members questions. I'll keep it here at the chair. I'm very supportive of this proposal as we need to update more often than every 15 years on a hard cap, especially in light of the fact that CMS has already approved some of the applications that exceed that cap. It's time for the states to make the change.

With that, I will. Thank very much. Panel nine, we will move on to issue 10. Issue 10 is also proposed trailer Bill on the Radiologic Health Branch licensing and certification. This proposal is being presented by Miren Klein, Director for the Center for Environmental Health at CDPH. Please begin when you are ready.

Sure. Good afternoon. So this proposal will make changes to licensure, denial, suspension or revocation procedures for medical X ray machine and radioactive material users. So currently, CDPH is only able to take disciplinary actions on licenses for crimes specifically committed during the performance of an X ray duty. So current law prevents CDPH from taking disciplinary action on a licensee who has been convicted of a crime that is substantially related to their duties.

These proposed changes will bring the department's licensing program into alignment with existing standards for similar licenses that are already issued by other state entities, such as the California Podiatric Medicine Board, the Pharmacy Board, and the Physical Therapy Board. The proposal also expands the civil Penalty authority that the Department currently has to cover all statutory and regulatory violations related to medical, radioactive material and X ray machine use. Happy to answer any questions that you have.

Department of Finance Shelina Noorali, Department of. Finance Nothing further to add.

LAO Will Owens, LAO we have no concerns with this proposal.

I'll bring it up to the dais for any Members questions. I'll keep it here at the chair. I just want to clarify, so currently you're only able to charge if it's regarding a mammography procedure, is that correct?

Correct. So the civil penalty authority that we currently have that tool, we can only use if an X ray technician is performing a mammography X ray, but any other X ray, we don't have the authority to be able to use that tool. This proposal will expand that.

Where did the origin of that come from? How did we expand it to mammography only? Why did that come about?

I think it's back a few decades ago when the state adopted the federal mammography statutes, and there was something that was missed at that time. And so we finally have decided that it's time to kind of resolve that.

Issue as well as technologies have evolved which also are more invasive and require us to make sure that the laws are following them. I'm very appreciative of this proposal. With that, I will thank Panel 10 and we will move on to issue 11. Issue 11 is on DHCS's BCP on the Medical Short term Community Transitions program. First we have Lori Walker. Please begin when you are ready.

Thank you. The Department is requesting extension of two existing limited term positions and expenditure authority of $286,000 beginning in fiscal year 2425. Extension of these limited term positions is necessary to enable the Department to continue to implement and maintain the workload for the short term Community Transitions Program.

This program creates an expedited path for residents in long term care institutions to receive transition coordination services to assist them with transitioning to a community based setting and connect them with long term services and supports that they will need to remain at home or in the community, thereby reducing the risk of exposure to COVID-19 the short term Community Transition Program was extended by the Legislature in response to ongoing COVID-19 public health emergency.

The CTP program funds transition services for beneficiaries that have been residents of long term institutions for up to 60 days. If a beneficiary has been a resident for over 60 days, the services are provided through a companion program called the California Community Transitions Program, which is funded through the federal.

Money follows the person grant approval of this proposal will allow the Department to continue to transition eligible individuals from inpatient facilities to the community setting of their choice sooner than what was allowed under the Medi Cal Home and Community Based Services Program and generate ongoing long term savings for providing services to individuals in the community instead of Medi Cal inpatient facilities.

The Department acknowledges that previous uncertainty about the continued federal funding for the money follows the Person grant program, directly impacted provider participation in the CCT program and supports permanent extension of the money follows the grant program. There is more stability in the CCT program over the last two years as the Centers for Medicare and Medicaid Services has approved funding allocations through 2027, with the flexibility for states to draw down and expend the year of funding plus four additional years going to 2031.

The Department agrees with stakeholder feedback that the services made possible through the CCT program are critical in assisting individuals to access services in settings of their choice and has worked through CAlam to establish the infrastructure to continue transitional case management and transition services through enhanced care management and community supports.

The ACM benefit available through managed care plans implemented a new population of focus January 1 of 2023 for adults nursing facility residents transitioning to the community that was specifically built using the money follows the Person CCT program as a model that also applies to the community services Nursing facility transition to a home and community support benefit that managed care plans can elect to make available.

Building and expanding the availability of institutional transition services through the State's Medi Cal Managed care delivery system removes reliance on a non permanent funding source and will also drive the development of these services and supports in communities across the state where the CCT program is not currently available. In regards to the reporting East Bay Innovations is requesting from the Department, it's unclear at this time if this is a one time data request or a request for ongoing reporting.

The Department should be able to provide the information requested, although noting that demographic data will be dependent upon the data that the Department has required collection of historically happy to address.

Our next speaker is Tom Hinez, who is joining us remotely.

Hi, thank you. My name is Tom Hines. I'm the Executive Director of a nonprofit called East Bay Innovations. Bay Innovations is a California community transition service provider. Has been since 2009, EBI has transitioned 300 people, approximately 300 people, from skilled nursing facilities back into their own homes. The history of CCT goes back to 2007. It was started when California decided to participate in a federal demonstration Medicaid demonstration project called Money follows the person.

CCT assists people who are medical beneficiaries and who have been in skilled nursing facilities for longer than 60 days. CCT enables providers like East Bay Innovations to provide intensive housing searches for people who are in skilled nursing facilities to locate and secure a home to help pay for deposits first month's rent to help pay for accessibility modifications to make their new home suitable to move in considering their disability and mobility issues.

Also, it helps to pay for assistive technology, things like lifts and Hoyer lifts, overhead lifts, shower chairs, adaptive equipment to help people be safe in their own homes. At EBI, about 75% of the folks that we've served through CCP are folks from communities of color, and 72% are people who are over 55 years of age. EBI also connects people to long term services and supports like in home support services.

As a CCT provider, we help people access IHSs and then hire and train IHSS workers as well as apply to beyond the home and community based alternatives. Waiver Unfortunately, CCT's funding rates have not changed since it was started in California in 2007. The rates are still the same as 2007, even though medical funding rates for skilled nursing facilities and other institutions have risen significantly over that time.

The previous speaker alluded to the federal Demonstration Project money follows the person being not extended in 2018 and then extended twice for short periods of time. That uncertainty has led to many agencies that provide CCT services, like EBI, to discontinue providing the service. But just as instrumental to the decrease in CCT providers is the inadequate rates that we've been living with for 16 years. In 202014,000 people in skilled nursing facilities who are medical beneficiaries expressed an interest in hearing more about the CCT program.

But there's not enough. There's only 16 providers providing these transition services in California right now, so there's no providers left to meet the needs. Even though transition services result for almost all parties who transition in a significant cost savings to the state over their institutional terms. The previous speaker alluded to Cal Aim being as a vehicle to continue these transition services. Unfortunately, Cal Aim was not developed to parallel the funding that's available through CCT.

So even though CCT's rates have not been increased in 16 years, many of Cal aims benefits to help people transition are actually less than the CCT resources available. That's right, less. And then there are some several troubling lifetime caps in the Calais program that do not exist for the CCT program, thus serving to limit people's access even more. This is an incredible health equity issue and access issue for Low income communities that have no chance of transitioning into their own home without a service like CCT.

So I appreciate the opportunity to speak and any questions? Sure.

Department of Finance Hersh Gupta, Department of Finance Nothing to add at this time.

LAO Luke Koushmaro with the Legislative Analyst Office. No concerns with this proposal.

Bring it up to the dais for any Members questions? I'll keep it here at the chair just to contextualize.

I believe there's 1000 nursing homes, and if we have 16 providers for the CCT, and in light of us not increasing rates from 2007, does it necessitate us to look towards it, since ultimately we're finding cost savings from these transitions as a system and hoping you can comment on whether we have an adequate number of providers currently in the state for the number of nursing homes we have.

Thank you, and I'd like to turn it over to my colleague.

Good afternoon. My name is Susan Phillips. I'm Deputy Director for Healthcare Delivery Systems at the Department of Healthcare Services. Can you hear me? Okay. Okay.

So in terms of the number of providers, I will say that is the goal of Calame, with enhanced care management going live for the population of focus for adults who are currently residents of nursing homes that went live January of 2023, so just a few short months ago. And so we are looking to scale ECM providers through Calam. So we do have providers participating. We do have opportunities for CCT providers to also participate as ECM providers, and we are looking to scale ECM through managed care.

And in regards to the question about rate increases, at this point, we are willing to work and understand the request and receive the data to understand the rate increase request. Looking at utilization and also in the context of the calame and the ECM specific goals.

I'm trying to understand, and I thought you heard that. We're sorry for the pun. We're transitioning to, it seems, Calame. Does that mean we're moving away from CCT, or is this a long term program that will be around and that will be sustainable, or is this a temporary program that we're going to support until we can transition to Cali? Hoping you can comment.

Well, we recognize the benefits of CCT, which is really the ECM program, as well as community supports. That focus on this population was really built on the lessons learned for CCT, and we really do want to scale it. Statewide CCT, as was noted, is limited in terms of the providers and the take up right now, 1617 providers in 43 counties. And the goal of ECM is really to be statewide CCT.

As Lori, my colleague mentioned, the CMS has approved funding through 2027 and will allow for expenditure of that funding through 2031.

I'll stop, but it seems as if what you're saying is that they're not complementary programs, that in many ways they may be duplicative, that ultimately ECM will take the place of CCT. Sounds as if what you're saying as a way for us to scale and to grow it. Now, ultimately transitioning people to where they do the best should be the goal.

And if we can work with both CCT and calame to accomplish that goal, we will ultimately, as a state, see the rewards as well as the patients who will benefit from that. So I'm supportive, but just want to make sure that we're not duplicating processes that we're complementing. And it sounds as if the goal here is really to look towards Cal aim, seeing no further questions from the dais. We will thank very much panel 11 and move on to issue 12.

Issue 12 is the PACE Monitoring and Program Operations BCP. We will begin with Ms. Walker.

Thank you. The proposal Request Expenditure authority for 10 new permanent positions that are necessary for the Department to meet current workload demands to comply with federal and state requirements related to the Administration, operation, and monitoring of the program of all inclusive care for elderly or PACE.

The positions requested will allow the Department to establish a dedicated Pace monitoring unit and increase operational capacity to meet the continuous, increasing volume of pace nursing facility level of care determinations it must perform for every new participant evaluated for enrollment in pACE, as well as annually after enrollment. The positions requested also include legal support for the program and its continued growth.

Federal pace regulations require the state administering agencies conduct on site audits of new pace organizations annually during their first three years of operations, and additionally, the DHCs contract with PACe organization requires that DHCs will conduct on site audits of mature pace organizations outside of their trial period at least every three years or is appropriate to address program compliance.

All PACE audits include both on site and desk review components, and the dedicated PACE monitoring unit established with these positions will also be responsible for Pace quality monitoring functions that would include review of quarterly pace, quarterly reporting, intake, and investigative complaints, monitor pACe organization compliance with licensing requirements for PACE organizations that fall under the DHCS Authority and monitor Corrective action plans and we're happy to address questions.

Department of Finance Hersh Gupta Department of Finance Nothing at this time.

Lao no concerns at this time. Bring it up to the dias for any members'questions.

Dr. Jackson, certainly understand the need for this. My question is for the long term, obviously this service will probably be needed more and more as we get down the road. Do we have a projected growth plan for this as we know that the aging population will increase? Thus, I'm thinking one plus one equals two. So I'm thinking we're going to see continued budget increases when it comes to this. Am I correct in that?

Do we have any anticipation what the long term growth of this program would look like?

Sure. So we definitely have seen growth in the PACE program over the last few years. So just in terms of the program growth, there has been a 75% increase since 2018. So back in 2018 11 pace organizations, and now we have 23 pace organizations in 25 counties. And currently at the Department, we have several applications, 28 new PACE organization applications and service area expansion.

So just to concur that it is in fact growing, we are looking to build the infrastructure to ensure that we can conduct appropriate monitoring and oversight that we can review the applications timely. And so at this point, this is our request, and we may need to assess in the future.

Right. Of course. We have the master plan for Aging, and I'm wondering, are you looking at those growth projections when it comes to this program as well? In terms of, by 2030, we're supposed to have a very, I mean, this seems to be a big increase, but the big, big one hasn't hit us yet. Right. So I'm just wondering, how closely are you aligning with those growth projections when it comes to this program? Is it in alignment in terms of the infrastructure you're trying to build out?

Our assessment that it is in alignment, but we will definitely monitor that.

Thank you. I'll elevate, if I can, having visited a PACE program in downtown Fresno, how culturally and linguistically competent they can be to address certain subpopulations. We have a local mong population that struggles to not be socially isolated, and the Pace center creates an opportunity for them to be together to have their health needs met to address any psychological needs that they have.

And really, I'm impressed with this model as a means for us to address some of the inequities that have been present within systems with it. I will thank very much this panel, and we will move on to issue 13. It Issue 13 is a trailer Bill proposal on post eligibility treatment of income. Ms. Walker, when you are ready.

Okay. The Department is proposing trailer Bill to clean up language to align state statute with federal guidelines. The trailer Bill addresses how the Department describes the cost sharing provisions for individuals subject to the post eligibility treatment of income and the spend down of excess income required for individuals to become eligible for Medi Cal through the medically needy program. California currently operationalizes its long term program in the medically Needy program.

Institutionalized individuals are transferred and are transitioned into the medically needy program where the post enrollment treatment of income rules are applied for ease of Program Administration. The scope of the individual's coverage remains the same as their original program coverage prior to long term care placement.

The Department has used the term share of cost to describe the post enrollment treatment of income rules for many years when individuals move into long term care and have applied the post eligibility treatment of income rules correctly and in accordance with federal regulations.

The Department uses the share of cost terminology interchangeably to explain both the post enrollment treatment of income and the concept of spend down of excess income, causing confusion for our consumer advocates and our Medi Cal Members, Centers for Medicare and Medicaid Services and consumer advocates raised concerns during the continuous coverage period during the public health emergency with the use of the share of cost terminology and notices of action.

When individuals moved into long term care in which they were now subject to the postal enrollment, treatment of income rules and share of cost when prior to their placement in long term care, they had no cost Medi Cal. This appeared as if the Department was not being consistent with the federal policies on continuous coverage and imposing cost sharing incorrectly.

The Department was requested to revise the notices of action to more appropriately communicate with beneficiaries the post enrollment treatment of income rules in a consumer friendly way and to remove the share of cost terminology and to align our long term care notices of action with the department's operational practices.

The Department is partnering with the California Healthcare Foundation to do focus group testing to make sure meaningful consumer facing language is used and the trailer Bill does not change the way share of cost or post enrollment treatment of income is calculated or administered for the medically needy beneficiaries.

Department of Finance Hersh Gupta Department of Finance Nothing further to add.

Aleo we have no concerns with this proposal bringing it up to the DAIS. It's a much needed change. Thank you very much for Panel 13.

Thank you.

Move on to Issue 14. Issue 14 is an oversight issue on delayed payments to skilled nursing facilities. First, we will hear from Jennifer Snyder, legislative advocate for the California Association of Health Facilities. Please begin when you are ready.

Good afternoon, Jennifer Snyder with Capital Advocacy here today on behalf of the California Association of Health Facilities. We appreciate the opportunity to comment on this item, which is relative to skilled nursing facility payment delays. So, effective January 1 of this year, all long term care facilities were integrated into medical managed care. There were 31 counties where that was very new to them and to the nursing facilities that worked within these transitioning health plans is what we call them.

Their lack of experience and knowledge as to how long term care is funded and coordinated is having a significant impact on contracting and timely payments for our transitioning populations that either are currently in nursing facilities or obviously being referred to them. So the nursing facility Members of CAF are experiencing a number of Cal AEM implementation issues that are relative to plan payment and to contracting concerns are twofold.

First, because some managed care plans are not following through with their contracting responsibilities, nursing facilities are being forced to take medical patients either out of contract or out of network. Some plans are refusing to actually contract, instead requiring some types of letters of agreement, LOAs or what we call them.

So without contracts, facilities are doing their best to secure out of network payments or request a contract agreement, but without any requirement for a plan to contract, many facilities are left without any guarantee of payment for current Medi Cal patients or future referrals. So CMS rules require that providers have to be in network to receive any directed payments. And directed payments can include any rates that are directed from state government, and that does also include any medical program rate.

Facility rates that are also what we talk about related to quality payments that are under kind of the new rate setting system from AB 186 last year. It includes quality payments that facilities are incentivized through meeting certain quality standards. The problem is that CMS requires that these facilities be a network to qualify for those quality payments. So unfortunately, due to those CMS rules, skilled nursing facilities that are not contracted aren't eligible for those patient days that are not under contract.

Now, of course, they still have to adhere and meet the quality standards, but they can't actually get to a point where they can be qualified for those days just by the fact that they're not contracted, which in many cases is completely out of their control. So second, since January 1, many, if not most nursing facilities have experienced significant payment delays for services they have provided to their medical residents.

Nursing facilities, as we know, rely heavily on state Medicaid funds, which on average is about 70% of patients that they serve. So as of today, it'll be four months without some facilities receiving any reimbursement for services provided. Plan's ability to processing to process transitioning medical populations, including recognized newly enrolled beneficiaries and recognizing the DHCs prior authorizations, have caused significant delays in facilities ability to submit claims.

There's a requirement in state law that health plans must pay a provider within 30 days, and then after 45 business days, certain interest starts applying. Unfortunately, there are many managed care plans that are not adhering to this rule. So due to these circumstances where a plan is still not understanding kind of the long term care space, they're issuing erroneous denials for rates that are already set by the state.

So CAF would suggest two amendments to the Calam trailer Bill that the Department of Healthcare Services has suggested. First, we would ask that the trailer Bill Language require Medi Cal managed care plans to sign, when they do sign contracts, to sign them retroactively, and this will be utilized really for the purposes of directed payment.

So in cases where facilities are able to secure a contract, and we hope all of them will, that can be retroactive to January 1 so they can at least qualify for the patient days that they've served medical patients. And then second, we would ask that there will be a requirement for health plans to report their network utilization and timely payments that are specific to long term care health facilities and the system issues that are specific to long term care health facilities.

This will make sure that we're not seeing a broad averaging of how payments are being adhered to. Timeliness of payments, because right now those types of information, at least from what we understand, is an average and it's not specific to long term care. So we can have a better sense and the Department could have a better sense of where we're seeing problems related to timely payment.

So these two requested amendments will strengthen what we believe are the Cal aim statutory requirements and ensure that Medi Cal beneficiaries have stable access to SNF services. I appreciate your time. Thank you.

Next we have DHCS Director Michelle Boss.

Good afternoon, Mr. Chair Members Michelle Boss, Director of the Department of Healthcare Services. We continue to keep communication channels open with our managed care plans and our skilled nursing facilities to monitor the delivery of long term skilled nursing facility benefit and to directly intervene in particular situations to address noncompliance and to be informed of any systematic actions needed to clarify policies in the market.

Over the last few months, we've been monitoring the market and taken some systematic action to address the concerns, and we've implemented some all plan letters and have an all plan letter forthcoming to remediate some of the concerns we're hearing. We issued an APL back in December and clarified it in March, addressing facility concerns regarding the ability for managed care plans to pay higher rates than the fee for service per diem for exclusive services, which DHCs clarified are not subject to the directed payment policy.

The APL laid out existing MCP or managed care plan requirements pertaining to continuity of care for skilled nursing facility residents to be able to remain in their facility and have continued access to their out of network provider and services, including therapy services and durable medical equipment. The APL also clarified transportation requirements that managed care plans are obligated to provide to their Members, particularly transportation to appointments like dialysis. The APL included new guidance to address operational concerns.

For example, it required the managed care plans to have a long term services and support liaison so that SNFs have a point of contact at the plan to support questions that they may have. Also requires managed care plans to train their providers on claims protocols.

Since many managed care plans have their own processes and systems that they use to reimburse services to broadly address the concerns related to the prompt payment of claims, we are working on a timely payments APL that reminds managed care plans of their existing contractual obligations to pay claims timely. Managed care plans are considered out of compliance if they do not meet certain thresholds of timely payments.

Specifically, they must pay 90% of clean claims in 30 days and 99% of claims clean claims in 90 days, and this will clarify when that clock starts to be very clear both to the plans and providers. We are targeting to issue this APL in June of this year. Additionally1.0 of confusion for the market was what services were considered part of the directed payment for a facility rate versus services falling outside that rate in which directed payments do not apply.

We clarify what services are part of the directed payment rate and what may be further negotiated between the plans and the facility. Although we do not intervene in contractual relationships between plans and providers, we have followed up with specific plans with concerns that we've heard from some of the facilities and have directly intervened to kind of keep tabs on their prompt payment.

We have broad enforcement authority to impose sanctions for noncompliance with regard to the Workforce Quality Incentive Program and the letters of agreement we have communicated to all plans that they must transition from minimum contracting requirements for network adequacy and readiness to ongoing network capacity building to ensure appropriate access to skilled nursing facilities.

They are aware that their Letters of agreement are not considered network provider agreements and we have encouraged our managed care plans to retrospectively effective date their contracts to the beginning when the first letter of agreement was entered, kind of to address the first issue that Ms. Snyder raised. We continue to monitor our managed care plan's efforts to build its network capacity and look forward to continuing conversations with the nursing facility industry.

Department of Finance Hersh Gupta, Department of Finance we appreciate hearing from Ms. Snyder and would be happy to work with the relevant parties at the appropriate time.

LAO Andrew Duffy on thank you. Bring it up to the DAIs for any members'questions.

Dr. Jackson Ms. Snyder, obviously I share your concerns in terms of timely payment. I come from the nonprofit sector. I know what it means when you got bills to be paid, when you got people to pay, and you are not getting properly compensated as a rarely practical time. Right. You're not asking for 24 hours. You're not asking right. When you hear the response to be able to rectify this issue, are you hopeful that this will help with the issue?

Definitely pleased to hear that the department's actually taking some really good action to communicate with plans and keep them a little bit more accountable. Definitely pleased to hear that. I think, I mean, I heard at least two new APLs I think the concern will continue to be that the Department, to some extent, will do all they can and you will still have plans that will not be compliant, and so you'll have facilities that will be harmed and their patients will be harmed because of it.

Some of that will remedy itself as we transition. Most of this is going to be in this first year. And so that's really why we're pushing. The first proposal I talked about is to find some way where contracts can be retroactive or required to be retroactive, and we only need that for a period of time. This window of opportunity, I think, is the concern is it just won't be remedied. And you have facilities that really do rely on those quality payments when they qualify. So I would say I feel better. I can't say I'm 100% better.

And are you saying this is the big, is this all you plan on doing, or is this some other solutions you're also working on? Right.

Mean, I think to Ms. Snyder's point, this is the transition period. And if there are plans that are systematic, kind of non compliant with their timely payment or just in good faith discussions with the skilled nursing facilities, we are happy to engage in those conversations. But to systematically require across the board plans to have certain contracts, that's not a position that the Department would be in to have this kind of broad based requirement, but happy to intervene as different situations arise.

And the authority that you have in terms of penalties, are they sufficient enough for them to actually care.

Plans don't want to be sanctioned by the Department.

Some sectors are like, well, we'll rather accept the penalty. Right. We'll definitely. Obviously looking forward to continue to closely monitoring this because we really got to make sure we make people whole.

Yeah. It's very important for us that our providers are paid timely, they're providing a service, and they should receive the payment for those services.

Absolutely. Thank you.

Bring it up to the chair. Ms. Snyder, I wanted to get the data point. You said that there were 31 counties who have new transition health plans, and I believe within that, you said 70% of the patients being seen have not had reimbursement thus far. Can you clarify that? 70%, yeah, I apologize.

So if I was a little bit confusing on that. The 70% I used is the average number of medical patients that a nursing facility cares for. So on average, nursing facility, every nursing facility is about 70% of their population are medical patients. In some cases, it can be upwards of almost 90%. Right. And others can be a little bit less. So I apologize for that, we don't know exactly how many have received non payment.

We could tell you I would only be kind of coming up with a very approximate and in many cases it is lack of payment based on a number of different issues. And they could receive payment for two of their patients, but not have it for the 50 others that they have or something.

To that extent it's safe to say, though, it's more than 10%. So this all plan letter that's coming out requiring 90% within 30 days would.

Zero yes, it's got to be at least 70% of our providers, if not more, that are having problems easily.

For Director Boss, if I can, what would it take? You said we have the ability to impose sanctions for non compliance. Having gone four months not receiving payment, it seems that I want to make sure we're doing all that we can. That what would it take, what type of non response would it take from the managed care plans to then how long are we going to wait before we insist that our facilities are getting reimbursed?

I think part of it is kind of learning the process between what plans require for a clean claim and kind of that back and forth between the provider. So a lot of this is also education and kind of the relationship between the plan and provider to get to a point where the claim is processible and they think they can pay it.

And so working with our plans on how to define and kind of do more provider education as well, each plan is responsible for educating the providers on what that process might look like. And so that is part of our, kind of the APls that we are working on. And this goes across beyond just skilled nursing facilities. It's really the relationship between the plan and the provider. To ensure Prop payment.

Are we not requiring them to report network adequacies related to SNFs as it's reported by CAF within the agenda, or do you have that ability?

Plans are required to reflect their skilled nursing facility network adequacy and kind of their provider networks. I'm not quite sure I understand the request that CAF has with regard to the data.

I may ask Ms. Snyder to comment.

Sure, no problem. So ours is more around timely payments. It's our understanding that at least what's reported by the plans to the Department of Healthcare Services is their compliance overall with timely payments across their entire providers, not just certain categories of providers. So what we're hoping for is that there is a little bit more specificity as to their timely payments relative to long term care facilities.

So we can see where there are more outliers, because if you're looking at provider payments as a whole, they're probably doing Pretty well at this point with other providers that they've been contracting with for a long time. So it's more specific to timely payments as opposed to network advocacy.

Awfully hard to think we can have adequate networks if plans haven't contracted with the health facilities that we have, and so believe that should be a major motivation for many of these plans to get into compliance with network adequacy and then would push on. How do we ensure that we are meeting that need from the Medi Cal managed care plans? With that, I will thank very much this panel and move on.

We are going to do something a bit nontraditional. We are going to accept public comment on issues 1 through 14 at the moment, as well as we will take public comment after the completion of all the issues today, but wanted to give the public an opportunity to participate now and this will be stopped or we will take a break prior to 05:00 so we can begin with the order of business directly at 05:00. Right now though, Operator, we are ready to receive.

We will begin with any public comment in the hearing room, first, for issues one through 14, and then we will turn to you, Operator.

Thank you, Mr. Chair, Members. Tiffany Whiten with SEIU California. We support the efforts to hold hospitals accountable and ensure nurse to patient ratios are met. We also support the proposal by CAF to amend the CalAIM Implementation Trailer Bill in order to address the need for our long term care facilities. We definitely appreciate the updates from Director Baass and look forward to the collaboration as we continue to figure these things out to ensure that the problems are addressed adequately. Thank you so much.

Thank you.

Jennifer Snyder with Capitol Advocacy, first on behalf of City of Hope, I just wanted to comment how much we appreciate under issue five, the department's request to add money for the implementation of SB 987, which is the Cancer Care Equity act. And then second, on behalf of WelbeHealth. They're very supportive of the department's BCP relative to increasing funding for the PACE program. Thank you.

We will take that as the end of public comment for now. Operator, we will turn to any public comment that is on the phone.

Thank you. For any public comment, you may press one and then zero. We will go to line 25.

Thank you, Mr. Chair and Members. Vanessa Cajina, on behalf of Cal PACE, the Statewide Association of PACE Providers, speaking in support of item 12, DHCS's BCP to properly support PACE program oversight and functions. And we really appreciate the staff recommendation and the agenda. We also appreciate the Committee's remarks today with an eye of the future so that trail elderly Californians can age safely in their homes and communities, especially folks from linguistically and culturally underserved communities.

We really appreciate the department's partnership in making these complex programs operate properly and respectfully ask that the BCP be approved at the appropriate time. Thank you.

Thank you. Next caller, please.

Line 26.

Hello Chair, Members. Autumn Ogden-Smith with the American Cancer Society Cancer Action Network here to support item number 5 on the Cancer Care Equity Act. While amazing advances in cancer science are creating more effective treatment and cures for cancer patients, many patients with complex diagnoses are not given the same opportunities to benefit from this level of care. The impact of care disparities are greater for patients who are medical beneficiaries, especially those from underresourced communities, resulting in less than favorable five year outcomes.

Supporting this budget request will ensure that patients with complex cancer diagnoses receive the care that they need, and we respectfully ask that you support this measure. Thank you.

Thank you. Next caller, please.

Thank you. Line 14.

Good afternoon. Diana Douglas with Health Access California. We would like to express support for issue six, the requested increase in funding to support the Covered California $1 Premium program that ensures everyone can enroll as seamlessly as possible without the previously burdensome extra dollar charge. Thank you very much.

Thank you. Next caller please.

Thank you. Line 16.

This is Catherine McBride. ...I'm sorry, but I'm calling regarding issue number 33 regarding gender affirming care. SB 107 never should have passed as it takes away parental rights. Adding 321,000 to the budget to implement special investigation due to an increase in complaints regarding release of medical records would be a waste of taxpayer dollars. Healthcare providers should be allowed to release medical information with proper subpoenas and authorization from patient or representative, especially regarding minors.

If a minor decides to change gender, they should never be kept a secret from parents or representatives. Considering the countless stories of transgender regret and how many consider detransitioning, I'd be surprised if any parent would approve a Bill that supports caregivers being kept in the dark regarding this very sensitive matter. Please vote no on issue number 33 and consider spending the money on increased mental health care for those suffering from gender dysphoria. Thank you very much.

Thank you. Next caller, please.

Line 27.

Good afternoon. Kelly Brooks on behalf of the Center for Elders' Independence, a PACE program serving seniors in Alameda and Contra Costa counties, calling in in support of the PACE Budget Proposal. DHCS needs to be adequately staffed to increase their capacity for pace administration and oversight. The department's staff is critical to our mission to serve real seniors. Thank you.

Thank you. Next caller, please.

Thank you. We have no further public comment in queue.

Thank you. I will take that as the conclusion for now. We will take a break until 05:00 when we will come back to our order of business issues 15 through 19. We are recessed until 05:00 p.m.

We're going to call the meeting back into order. I would ask Dr. Ewing to come forward. We had been waiting on Daryl Steinberg, Mayor of Sacramento, and haven't seen him log on. So if you're having any technology challenges, please feel free to reach out to the Budget Office. But since we have not seen him online up to this point, I believe we're going to begin with you, Dr. Ewing, and we'll come back as needed.

Thank you, Mr. Chair and Members. Toby Ewing, on behalf of the state's Mental Health Commission, I appreciate the opportunity to join you this evening. I was hoping to go second and hear Mayor Steinberg, so I'm a little caught off, but I really appreciate the chance to join you.

And we provided some written commentary for panel one or item one, which is really asking about sort of the origin story of the MHSA, and so apologize that it's a little lengthy, but there really are a handful of key takeaways from the origin story of the Mental Health Services act that I think are very relevant to the governor's modernization proposal that is in front of the Legislature, that will be in front of the Legislature shortly.

And one of them is really to recognize that Prop 63 was born out of a multi year consultation process, really building off of work that the Little Hoover Commission did over several years. And the reason that's important is because the MHSA is considered by many in this community to be community owned.

It was really the product of hundreds of hours, hundreds of meetings of consultations and engagement that started with an understanding of where California's mental health system was at the time and thinking about what should the mental health system look like.

And so the goal really was to draft very broad goals with specific strategies, but also with flexibility built in to the Mental Health Services Act that will allow local agencies to make decisions that are responsive to their communities in ways that are tailored to their geographies, to the political realities of this very diverse state that is California. And it was designed to benefit from emerging research. And so, and I can give you some examples designed to require community consultation with a mandate for prevention and early intervention.

This whatever it takes approach that is inherent in the full service partnership programs that are a mandatory component of the Mental Health Services Act. And that calls for innovation that recognizes that we can do better. And so it's important to reflect back of where we were 20 years ago when California rationed access to care through medical to only the most ill, the most sick Californians. And there was no prevention, and there was no mechanism for continuous improvement.

The MHSA is really designed around a future where everybody who has mental health needs has those needs met, and we're not there yet. We're far from it. The challenges we face, actually, I would argue through the perspective of the work that we do at the Commission, are more about implementation than policy. Senator Member Jackson has raised issues at these budget hearings about whether or not there's a profound sense of urgency in addressing the challenges that we have in our mental health system.

And that's where we were 20 years ago, is that we did not have that profound sense of urgency. The Commission was formed to actually sustain an aggressive and assertive voice for urgency around mental health needs, broadly defined.

And if you look at the membership of the commission, with two mental health peers, two family Members, two providers, but also educators, to public safety officials, to employers and a labor representative, it was really designed to be reflective of diverse voices across the state, to bring them together in a way independent of who was in the governor's office, independent of legislative leadership, because at the time, we did not have the support of the governor's office and the Legislature.

In fact, Gray Davis vetoed legislation to create a mental health Commission at the time, which was part of the reason why now Mayor Steinberg and others went to the ballot. In terms of accomplishments. One of the questions that are outlined in the packet, the prevention and early intervention component and the innovation component, are key foundational pieces. They are funding that is unavailable in nearly every other funding stream for mental health.

Again, if we go back 20 years, and I want to keep referencing this because I want to alert you to the likelihood that some of the reforms may result in returning to how we had organized and fund mental health services prior to the MHSA, an over reliance on Medi-Cal to the point where we were restricting access to services dependent on whether or not Medi-Cal would pay for it, the MHSA does not have restrictions other than no supplantation.

I argue that under innovation, if you can convince the Mental Health Commission that filling potholes is good for the mental health of the community, that that isn't acceptable. There's no restrictions beyond the idea of engaging the community and having fiscal and policy decisions around local behavioral health strategies to be driven by what's happening at home. The dollars are very fungible. PEI is important not just as a funding stream.

It's more important as an attitude that we mandate prevention or early intervention in ways that is not true in any other funding stream. It is a funding stream, but its most important value is it forces us to have community conversations about what does it mean to prevent, what does it mean to intervene early? And are we being successful in terms of the expectations of the statute?

And given that it was a statute that was driven by a voter initiative, it really is the voice of the people who are saying prevention and early intervention is key. More than that, it defines prevention and early intervention in the context of avoiding homelessness and school failure and criminal justice involvement, avoiding unemployment and child welfare involvement.

If you take the language of prevention, early intervention, the MHSA, and you turn those seven negative outcomes that are discussed, it lines up very nicely, very close to global definitions of well being. The Mental Health Services act is pushing our behavioral health system to be a driver of well being for all Californians. So have we been successful? Absolutely we've been successful in that we're having these conversations around prevention in the mental health space at a time where there is not agreement of what that even means.

And so the MHSA is this catalyst to really push us to think differently beyond what we traditionally pay for and to think about how we do. upstream investments to really support the Californians who are at risk. Local communities have used PEI dollars in incredibly flexible ways. I'll give you an example of an out of the box PEI strategy that was originally funded with innovation. I'll give you two. In Fresno, they funded a community garden to serve their Hmong community.

So remember, Chair Arambula's designed to recognize that the Hmong community didn't have the language around mental health, and they could actually leverage these cultural practices of gardening to engage that population, and they put services next door.

And so it became a very creative, low cost, highly visible, highly valuable prevention strategy to engage a community that otherwise was not accessing services. We have more recently partnered with Solano County and other counties to leverage innovation funds to improve how we create access to services. In Solano County, they saw a 300% increase in access to care for their communities that were least likely to access behavioral health services, again through robust community consultation, early intervention, and prevention work.

We know that because of the testimony that you heard at your last hearing, the young woman whose parents had very high quality health insurance and were not able to get her into an early psychosis program, and they were able to get her into an early intervention program with a grant. That program today is funded with MHSA Dollars. The strategies that are available, that are necessary, that are not available under Medi-Cal are funded with MHSA.

So prevention has been essential, PEI has been essential to shape how we think about mental health opportunities and to ensure that we can cover the difference between what an individual needs or what a community needs and what Medi-Cal is able to pay for.

I also want to recognize that in this question of Are we making progress in terms of prevention early intervention, that in the 2000s, when before the Mental Health Services act was passed, the idea of a schizophrenia diagnosis was akin to an end of life diagnosis, right? There was this just profound sense of, my life is over. That's not true today. That is absolutely not true today.

We have seen progress in schizophrenia treatment, in mental health treatment, akin to the kinds of leaps that we have seen in cancer over the last 40 or 50 years, where a cancer diagnosis for a generation ahead of us may have been seen as a death sentence. And now we know that prevention and early intervention absolutely work. The frustration that I have that you may hear in my voice is that we're even having this conversation.

We don't need to have a conversation about does prevention work or does early intervention work in terms of almost any other aspect of health care. And so these two components are essential in that they have actually pushed our county behavioral health partners to move beyond the traditional approach to behavioral health care, that is funding driven, and instead put in place a strategy that is need driven, born out of that community consultation, born out of those honest discussions.

In some places, they're more honest than others in some places across this diverse state, that the level of engagement with the community is more robust than others. But it is this idea that the law requires the behavioral health system at the local level to sit down with residents and have a discussion on these two opportunities.

One, are we doing everything we can to do the upstream work, to engage people early, and to invest in strategies that can prevent needs from cycling to be more expensive, particularly in terms of incarceration, hospitalization and homelessness? And second, are we doing everything we can to ensure that the services we have are best available? That innovation piece, having a prevention mandate and having an innovation mandate, I would argue, is essential. It's at the core of the MHSA.

And those pieces really were put into the MHSA in response to a scenario where a mental health system was driven primarily by medical prior to the MHSA. So I was going to say that three years ago, I sat with the mayor and we talked about actually wanting to change the formula to be 80% prevention, early intervention, which is how we should be allocating resources and 20% response to deep end needs.

I'm challenged to see how we find ourselves in this place where we've lost sight of the idea that upstream is not the priority, and that instead what we need to do is maximize responsiveness to diagnoses. Now, I want to recognize that the governor's proposal is tackling some just phenomenal challenges, and he is spot on in terms of the emphasis on homelessness, the emphasis on addiction, and spot on in terms of pushing Medi-Cal to be able to offer more upstream services. Right.

The MHSA was actually designed to be a counterpoint to work together with Medi-Cal so that Medi-Cal with the MHSA would actually give our communities the best opportunity to be as responsive as possible to needs that are occurring today and that are emergent.

And the reason I say emergent is because the fact that MHSA dollars are so flexible, they allow local agencies to spend those dollars on issues that we did not know about last year, that it's not driven by federal policy or even state policy, that it's really the most flexible resources that allow our systems to actually be responsive to not what we learned last year, but what we're thinking about in terms of the impacts today and tomorrow.

I've got a bunch of examples, but just in the interest of time. Andrew is shaking her head. Please know I will finish there and say I really look forward to hearing Mayor Steinberg's comments. Happy to answer any questions you might have about the origin. I did not cover what was in the handout because I gave it to us a handout. But I appreciate your time and happy to answer any questions you might have.

Thank you, Dr. Ewing, for your flexibility. It now is a privilege and treat to welcome to sub one the Honorable mayor of Sacramento and the author of the Mental Health Services Act, Daryl Frank.

That's better. I'm sorry. I think I was on mute. Good afternoon, Mr. Chairman. Chairman Arambula and Members of the Committee. Thank you for having me. I'm so sorry I cannot be with you in person. I tested positive. Yes. Yesterday for COVID and minor symptoms, so I'm fine. But of course, I shouldn't and can't be there with you. But I appreciate the technology and the opportunity to address you. So let me begin by saying I've heard most Dr. Ewing's testimony.

Let me begin by saying that not just as a pride of authorship statement, but genuinely, I am a big fan of the Mental Health Services Act. It has saved the mental health system in California literally. Its billions of dollars have made up for numerous recessions over the past 20 plus years and have served, as Dr. Ewing said, as a spur for innovation and positive change in the system.

If we did nothing else, if we changed nothing, it would still be a good and a great thing by virtue of what it is doing. At the same time, over 20 years after the passage of any major law, it is not only fair, but I would say it is imperative that we all take a look at its strengths and where it can be more effective.

Frankly, to put it in the most basic way, it's too much darn money to allow us to just go on for another decade or two without asking the fundamental question, are the dollars being used for the highest and best uses the most important needs of the people of California when it comes to mental and behavioral health? And on that question, I argue forcefully that it is time for not redoing it for the sake of redoing it, but for modernizing it. And here's why.

First of all, it's important, you asked the question, what was the original intent of the Mental Health Services Act? The original intent, and I can say this because I was the lead campaigner for it, was to alleviate the then version of California's homeless crisis, plain and simple. Rusty Felix and I In 1998, the late Rusty Felix and I in 1998 did some fuzzy math on the back of a napkin and said, we estimate there are fifty thousand homeless, mentally ill people in California.

We estimated that it would cost then about fifteen thousand dollars apiece, half from the state and half from federal matching funds to be able to provide wraparound services, which became full service partnerships to help them. And it was rough math, but it led to, in the years prior to the Mental Health Services act, my introduction as a freshman Assembly Member of AB 34 and AB 2034, which were the integrated services for the homeless mentally ill bills.

That led to fifty plus million a year to help people who were homeless and mentally ill in 30 plus counties in California. It was a great success. We showed significant reductions in homelessness, in psychiatric hospitalization, in jail time, and increased employment for people who were the beneficiaries of the whatever it takes approach. It was so good that it led Rusty and I and other Members of the Mental Health Movement to say, fifty plus million a year is not enough.

We ought to fulfill the promise made by the state in the 1960s and 70s when they shut the state mental hospitals to build a full system of mental health care for all Californians. And that led to the development of, and eventually the passage of the Mental Health Services Act. And yes, we were deliberate about saying that 20% of the money every year ought to be spent on prevention, early intervention, and 5% on innovation. And I will get to that in a moment.

But I think what's most important is to recognize that the definition of whatever it takes in AB 34 and 2034 has not necessarily been the way that 58 counties throughout the state have defined their own full service partnerships, which is the coin of the realm, wraparound services for people with severe and persistent mental illness. What do I mean by that?

Well, the homeless crisis has multiplied in California, and I say this not only as someone with a statewide scope here, but also as the mayor of a major urban city. The truth of the matter is that neither the Accountability Commission and I love the work that Toby and his team do, but the truth is the truth.

Neither the Accountability Commission or any of the counties have produced any data to show that the majority of their full service partnerships are actually focused on people in these tent encampments who are living or living in their vehicles, many of them who are suffering from a diagnosable mental illness and or drug addiction. And what's really happening in the counties, if we're going to tell the truth, is that they are helping a lot of people.

No question about it, the full service partnerships are good and they are working. But because addressing the problem of street homelessness is so significant, they are not focusing on the people in the streets. Now, there may be instances where they are where the full service partnership concept is applied, in fact, to people living chronically homeless, but the majority of those FSPs are not focused on that population.

And I think if there's anything to be taken from the governor's proposal that needs to be addressed, it's that a majority of those FSPs must be directed to people who are in the most vulnerable positions in our state.

If we really want to do something about homelessness, if we really want to see a relief for the thousands of people who are suffering and for the communities, because that's relevant, too, then this money, which, as Toby said, is some of the only discretionary money that the state has when it comes to mental health, more of it needs to be focused on the homeless population, and it just plain isn't.

Now the counties will produce some statistics saying that with a broader definition of homelessness that says that a lot of the money is going towards homelessness, not enough, and not enough towards the people who are actually living in the encampments. And it's not just the services. It's the assertive community outreach, the mental health Clinicians out on the streets in those encampments. There's very little coordination between cities and counties.

In our county and in our city, we worked for four difficult years with a lot of conflict before we got to a place that we were finally able to negotiate a legally binding partnership agreement that requires the county to add as many FSPs as are necessary to meet the need based upon the diagnosis. In the field, there's no such partnership agreement that I know of in any other part of the state. So that's one fundamental problem.

Let me talk about prevention and early intervention for a moment, because while Toby is correct that it was a major tenet of the Mental Health Services act and ought to continue to be, I'm sorry, there has not been any kind of a value of data to show that the wide variety of things that are funded through prevention and early intervention are actually making a systemic impact on the most serious problems and challenges we face as a state, not just homeless, but criminal justice, recidivism reduction, the number of kids that are kept out of institutional placement, suicide reduction.

Let me give you one very prominent example. We know that one of the best evidence based practices in prevention and early intervention is early psychosis identification and intervention. Because we give so much discretion to the counties and because these kinds of programs take some time to develop and maybe are more expensive than other approaches, we've got 30 early psychosis identification intervention programs that are going on in the state.

I'm told by the experts that we have the capacity to raise that tenfold, that we could easily serve teenagers and others who either have had a first break or are just short of first break. We could have 300 programs and meet the need. Instead, we only have 30. So what does that say to me? Not that the MHSA prevention and early intervention dollars are being wasted? No, just like the FSPs are not being wasted. The argument is different.

My argument is that it is far past time that we set more focused priorities. If early psychosis identification and intervention is the kind of early intervention we want to see more of, then we ought to say as a state to our county partners, you must fund this. Do it your way. We won't tell you how to do it, but you must fund this.

What would be wrong with saying, in that third bucket, for example, which I know is the most controversial part of it, I strongly favor one billion dollars set aside for housing. I think it ought to be tied to FSPs as much as possible. I support enhancing FSPs in the second bucket, but making sure that a high percentage of those FSPs are dedicated, including outreach to people on the streets.

In the third bucket, I would support a set aside for early intervention, just as the original act did, but I would require by the state that it be much more focused. Pick the five evidence based practices around early psychosis, around suicide reduction, around whatever else is going to help save lives for people who are the sickest of the sick. How about FSPs for transition age kids between the ages of 16 and 24 and make that one of your categories of prevention and early intervention.

In other words, without state leadership and state focus on the outcomes that we expect from these dollars, you're going to get the kinds of examples that Toby just described. I love the Mong story from Fresno. I've told that story many times. That story is 15 years old. What do we have now to show for prevention and early intervention to scale that is actually going to make a real than. And one other thing. The world has changed in some ways for the better.

We now have CalAIM, the Governor, because of the good budget, because of his leadership and the Legislature's leadership. Thank you, Chair Arambula and your colleagues. You've set aside five billion for youth mental health. As I said, you now have CalAIM MHSA should never be seen as just one piece of the system or just a separate part of the system. It should be seen as an integrated part of these other measures and initiatives.

And in that light, I think it is worth asking, can school based services be funded through CalAIM? Therefore, obviating the pressure on MHSA to do that prevention early intervention is absolutely right, but it must be focused, and I'm sorry, there's no evidence that I've seen that there is any focus statewide priorities to scale that would fulfill the promise of what we set out to do 20 years ago.

So, in conclusion, FSPS ought to be based more on the original intent of AB 34, and AB 2034 ought to be focused in collaboration with cities, the major cities of this state, on addressing and genuinely reducing the numbers of people living in squalor, on our streets, in their vehicles, or in these tents. Number two, housing is an absolute must, because without an ongoing source of funding, you remember several years ago, I pushed with then pro tempore Kevin De Leon the idea of No Place Like Home.

That has worked, but it was one time money. And frankly, if you do it again and you do the billion, I would direct as much of it as possible to manufactured housing and Low cost housing that can be built to scale and built quickly. But we need the housing money. The FSPs continue them, but enhance them and make them focused on the people who are living on our streets and on prevention and early intervention. Right on.

I think there's a lot of room to negotiate and to work out that third bucket, but focus it on three - four - five things that we can't otherwise do with the other money and that represent intervention for people who, without that intervention, are going to end up on our streets or in our jails. I'm happy to answer your questions. I think this is the time to lean in. I see what's happening out there.

I see that the Steinberg Institute, which I'm very proud of, the leadership of our entire team, are sort of on one side, sort of rallying with a similar message to mine. I see a lot of the traditional stakeholders who are our friends, who we did this work, MHSA, in partnership with, are saying, don't take the money that we have away from us because we'll get hurt and our programs will get hurt.

I urge us all to come together here, because where you can show that any good program will somehow be hurt by any modernization, we ought not to go forward until we can address that, either through MHSA, through CalAIM, or through other source of funding. But we can't have the usual debate here.

That is, look what X is doing to Y. We have an opportunity with this largest, this gift from the people to save more lives and what's going on on our streets and what's going on with teenagers and kids who are at such great risk if they don't get intensive, immediate help. It's too big for us to do business as usual. And so if my voice means anything, as the original author of this act, this does not need to be fundamentally fixed. Or redone.

It just needs to be modernized and refreshed to meet the most urgent needs of the moment, and I think it's a great opportunity. I hope it's seen that way, and I hope that we can all come together as people who really care about all those suffering needlessly out there. Thanks for having me.

Thank you, Mayor Steinberg. I will bring it up to the dais for members'questions and would remind everyone that we have five issues related to mental health that we'll be following. So any particular questions that you may have related to the history and overview, this would now be an appropriate time. Seeing none, I will then keep it here at the chair.

I really liked, Mayor Steinberg, how you said this was a gift from our people to save lives, that I'd like to ask Mr. Ewing, if I can. There was a suggestion regarding three to five things that we could recommend potentially to counties that would focus on prevention and early intervention. And I'm hoping you can comment on what you would believe those three to five things would be.

Thank you, Mr. Chair. And I agree with Mayor Steinberg. And in fact, the Commission has been bringing that focus, at least in our own work. And if we start with the three most expensive, most negative, difficult outcomes of homelessness, incarceration, and hospitalization, and we look at just the dollars that we're spending to react to those three particular challenges, we look upstream first. The step that should be just before that happens is, as the mayor points out, as full service partnerships.

So with your support, just last year, the Commission received funding to actually dig in and do the analysis that the mayor has called for, which is to understand what is working. And in fact, last week, we did a site visit. Assembly health staff were planning to attend, but ran into some barriers, and Budget Committee staff also were planning to attend. We will do another site visit to FSPs to really understand what's working and what's not working.

But the step up from that is, as the mayor says, early psychosis. We have an evidence based practice. It is available to less than 10% of Californians. The estimate is 27,000 Californians will develop psychosis this year, and somewhere in the 22 to 2500 will receive care, and about half of those will not actually receive evidence based, most effective care.

And so if we want to keep those folks who are most likely to struggle and need an FSP from needing that expensive intervention, the next upstream is early psychosis. We are arguing that upstream from that is youth drop-in because we have to create the trust and engagement with young people before they need the service and create unimpeded access to services.

You have supported the development of youth Alcove centers around the state as a globally recognized practice, invented, developed, really in Australia, that is expanding across the world. And we have two sites open, three more sites underway. The challenge we have with youth drop-in is the funding actually doesn't pay for the services that the youth need through this drop in model because it's a payer based financing model, not a need based response. And then the upstream from that is school mental health.

And we really appreciate the chance for some of the students who are involved in Mental Health Student Services Act funded programs in Imperial county having the chance to talk with you today. So now that leaves off justice involvement, suicide prevention, the needs of older adults, strategies to prevent kids in the child welfare system.

But those four would be at the core of really putting in place the prevention early intervention strategy that is responsive to those three profoundly difficult challenges that are bringing this topic to the table today, homelessness, incarceration, and hospitalization.

I'm going to bring up a point that I also believe I heard Mayor Steinberg say that currently a majority of FSPs are not being focused on those who are living in encampments. And I'd like to try and understand why we aren't using a whatever it takes approach for those who we know have great needs, who are unhoused and living in the encampments. Is this an individual county, or are we able to say that?

Is there a focus within the FSPs to look at those who are within the encampments?

You know, we spent, and I was going to raise this issue in the next panel. We spent some time working with the Department of Finance in order to secure the resources, in order to do the analysis that the mayor is mentioning and that you're asking. And we just got started with this work, and so we haven't had the chance to actually ask those questions.

We can point out, though, that there are requirements in the law for a majority of MHSA CSS funds to go towards full service partnerships, and we're not actually requiring counties to dedicate a majority of funds to FSP. So while I cannot speak specifically to the issue of who gets selected for FSP services, that's something we're working to explore.

I can agree that from an anecdotal perspective, that there are many people who are living on the streets who should be in a full service partnership, who are eligible for a full service partnership. And we know that there are funds available or that supposed to be available for that, that are not being made available. But that's the most I can tell you at this point in time.

Yes. Mr. Mayor Steinberg, just going to mean.

I think anyone who is living this at the local level, and this is not putting it negative on the county, because like I say, the full service partnerships I think are effective and the people who are the recipient of them are getting help and often life saving help. But anybody who experiences what is going on locally knows that there is not a primary focus on people living in tent encampments or living in their vehicles. There just isn't.

There aren't the interdisciplinary teams between cities and counties going out in these encampments. There isn't the offering of FSPs to large numbers of these people. If we really want to ask why, the answer is pretty clear. It's because it's really hard. It's really hard. And it's not creaming because the people that the counties are helping are in real need, but it's harder to do that consistent, persistent work out there.

And so the question is not just what is the Commission's policy here, it's what should be the state's policy. And what I'm asserting, and what I think the Governor is asserting, loud and clear, is that more of the priority needs to be applying these mental health resources, these precious resources, to the problem of chronic and unsheltered homelessness. And if we can agree on that, then we can agree on the formula for how to make that better.

Assembly Member Ramos.

Thank you, Mr. Chairman. Just a couple questions. The mayor brought up collaboration with the counties, and it taken some time to be able to work through some agreement to get to that point. Do we think that that is something that's holding it back in other cities also in the state, collaboration with the county and the resources that are there?

Yes. So I have been out there for several years now saying that providing help to people who are homeless ought to be a mandatory legal obligation of cities and counties and the state, for that matter, and care court, controversial as it is, where most of the attention was paid to whether or not the individual should have to involuntarily commit to services.

Nobody talked about the other half of what you did, which I thought was exemplary, and that is that a judge can order the government through the county, can require the government to provide the services to the people.

I think that the state should require in some way, cities and counties to develop similar partnership agreements to what we did in Sacramento, by the way, every part of the state might have a different version of this, but I think it ought to be required that cities and counties have legally binding partnership agreements that assign roles and responsibilities and require cities and counties to actually get out there in an intensive, assertive way and to do whatever it takes to get people off the streets.

Because absent that sort of legal prod, it's just not going to happen as fast as you want it to, because it's just not going to. I can tell you the law matters. Said it for years, and the law currently says that everything that cities and counties do in this area is optional and voluntary, and in some ways, the results speak for themselves.

So hearing that in some areas in the state, and certainly here, you were able to work through an agreement with the county, but maybe other cities and other jurisdictions aren't. So the ability to work through some of those challenges might not be in front of them. And so another question that I've been dealing with and trying to advocate around is direct funding to the cities. Cities that now aren't afforded direct funding because of the population base of some cities.

Largest city in my district is a 200,000 plus city that doesn't get direct funding, that still has to work through the county through some of those things. Do you think that if we did start to look at that direct funding and who actually gets it, would that be something that would be a step in the right direction?

Well, I think it would be. I mean, back in 2018, I believe it was the big city mayors were able to work with Chair Ting and then Governor Brown and the Legislature to get the first direct allocation under heap and hap to the largest cities in the state. But the line was drawn, and so medium sized cities did not get that same benefit. I would favor more direct allocation to the cities, but the counties are health and human services subdivisions.

I do not think cities are equipped, most cities are equipped to become health and human service mental health agencies. I think the counties are the appropriate body of government to do this. I think they do a good job. I think they're good partners. This is not a matter of are you doing a good job or bad job? It's a matter of priority.

And I think that the law, through the state, ought to in some way induce, require that more focus be paid to these most serious problems and not just homelessness. And here's your opportunity. The MHSA reform is an opportunity because it's not the state's money, it's not the county's money, it's the people's money. And here's an opportunity to work together to ask the people to modernize it and make sure that we state the priorities that the people of the state are demanding.

Thank you, Mayor. Thank you, Mr. Chair.

We'll begin with Chair Ting and then Dr. Jackson.

Mr. Mayor, thanks very much for joining us today. Just a quick question. When you wrote the ballot measure a number of years ago, you created an independent Commission, which Dr. Ewing oversees. Can you walk us through why you created an independent Commission that wasn't directly tied to the Administration? It wasn't directly tied to the Legislature. I mean, you were a Legislator back then, so you easily could have had it be part of the legislative body.

But if you could walk us through that thinking, that'd be great.

Sure. One, I'm always transparent and honest. Number one, it was a political campaign, and we wanted to convince the voters that there would be true independent oversight. And it also was the right thing to do to establish a Commission that would be independent of the Legislature and the Administration just in the very way you described it. This is a tougher question.

I still favor Independence, but I would like to see a greater alignment, certainly with the Administration, because one thing that has really bothered me over the years, and I don't know where to put the blame or the focus on this, but it's just been a source of great frustration, and that is that neither the state nor the counties nor the commission have ever been able to figure out how we produce regular outcome based data for what this gift from the people is actually producing.

And it has led to the most significant criticisms of the act. The Little Hoover Commission reports. I'm getting a lot of feedback. I'm sorry. Can you hear me?

You're coming in loudly and clearly on our end.

Okay. Sounds like somebody's, like, coughing, but maybe it's just my computer.

Someone is coughing. That's okay.

Okay. It's just loud. Okay. I don't understand why we do not have the technology to be able to allow the program providers to easily input basic data to the counties, to have the counties then be able to provide basic data to the state so that every year the Commission or the Administration or somebody can be producing the same kind of outcome based data that we did with AB 34 and 2034 back in 1999 and 2000, in the years after that.

It's so basic and so important because I know that this money has been well spent. I know that lots of people are getting help, but the public doesn't know the results. And so I hope that whatever comes out of this in terms of the status of the Commission.

And again, I think Independence is important that we also invest in whatever technology infrastructure is necessary to be able to do that basic outcome based data work so that regularly knows what's working, what isn't, and it might also guide these kinds of debates in a way that would be helpful.

So I hear you about technology and data. I think that makes a lot of sense. In your mind, how do you create this greater alignment with the Administration you mentioned without losing the Independence?

I don't know. It's something I'm thinking a lot about, and we're thinking a lot about the Governor does appoint most of the Members of the Commission. I know the Attorney General and the Superintendent and the pro tempore and the speaker also appoint. I don't know. There needs to be, I think, some greater engagement for sure, but I think maybe these months are an opportunity for the Commission and the Administration and the Legislature to figure out how you work more closely together.

Great. Thank you, Dr. Jackson.

Thank you very much. I agree with Mayor Steinberg in terms of some of the PEI programs. I actually, before I got here, actually administered one of the PEI programs for county, one focusing on early intervention and prevention for mental health in regards to African American youth. And one of the criticisms that we had when we were administering the program is, number one, when you do all the data, you do all the appropriate tools. It works, but you can only serve 15 young people per year.

And it was not scalable. And I think we have to start focusing more on interventions that can produce those type of results. Yes, but yet can also be scalable so that other community based organizations can implement it and in a way that is not as cumbersome and expensive as some of the things have been. Right. But I also think that we also need to create a better structure to work closer with the schools.

I think we're just in a perfect opportunity here in society while we're trying to recreate ourselves to say these are what institutions have done in the past, but that doesn't mean that they have to be that way in the future. And that includes our schools. The alcove. I actually visited one of them. Beautiful. Fantastic. However, the issue is that if you can get to us, hopefully we can help you. Our schools is the number one way to reach our young people in a consistent manner.

And we have to say at some point that our schools are not just for education, it's to make them healthy and they're not mutually exclusive. And, you know, my rants that you've been victims of and I think we meet tomorrow so you'll hear it again.

And the idea that we can't get to screening our young people in schools while we have thousands of young people suffering, well, I can't say right now they're out of school now suffering every day for things that they haven't exhibited yet in terms of behavior. We're waiting for them to get less healthy in order for us to find something to do with them.

So it's my hope that as we are thinking about reinventing the Mental Health Services act, that number one, they reflect our current priorities but also reflect the type of innovation that we need to have and the research based practices that we need to have to making sure that we can really meet these needs. So I appreciate the current discussion and looking forward to more to come.

Thank you. With that, we will thank very much this panel and want to wish Mayor Steinberg a speedy recovery. Thank you for joining us today.

Thank you very much.

We will now move on to issue 16, which is on the MHS OAC transfer to the Administration. We will begin with Stephanie Welch, Deputy Secretary of Behavioral Health, followed by quickly questions and answers from Chair Ting prior to him needing to leave, and then we will work through the remainder of the order as normal. We will begin with Ms. Welch when you are ready.

Good evening, Chair Arambula and other Members. Nice to see everyone. My name is Stephanie Welch. I'm the Deputy Secretary of Behavioral Health for the California Health and Human Services Agency. I'm also joined here by my colleague Kim Chin, who is an assistant secretary with the agency. I'm here tonight to provide an overview of the component of the modernization package proposal that includes moving the Mental Health Services Oversight and Accountability Commission under the California Health and Human Services Agency.

With this change, it is the intent of the Administration to seek support, to seek to support their work in being integrated, connected, and coordinated to the state's overall behavioral health agenda and system and the work that we have underway in several of our departments and the work that we do across agencies and the essential goal of that work being to improve the behavioral health of all Californians. Specifically, the proposal will support the Commission's focus on the critical need to examine data and outcomes.

I really want to underscore some of the points that Mayor Steinberg made and that we are in agreement with really wanting to have a core focus on Datas and outcomes to drive policy, and that is one of our intents with this proposal. We feel that this is also very consistent with the work that they're doing now and part of their core mission, and that that data would really drive policies and really drive where the state should be investing in best practices and high quality programs.

The Commission will continue to administer the programs that they are directed to administer by the Legislature and the Administration. The Commission will also continue to report to the Legislature. As Mayor Steinberg outlined, there is representation of the Legislature on the Mental Health Services Oversight and Accountability Commission, which we call OAC for short. I apologize if I do shorten it at some points, and they really play a critical role in stakeholder engagement.

When we had the disillusion of the Department of Mental Health over a decade ago, they took on some really awesome responsibilities to engage consumers and frankly, have done a really excellent job going beyond just the simple classifications of peers and family Members, but really looking at underrepresented groups, various cultural groups, older adults, LGBTQ plus, et cetera.

And then lastly, we would be requiring as part of coming into the Health and Human Services Agency that the Commission itself be led and managed by a Gubernatorial appointee, which, of course, would be subject to the checks and balances that exist in the Legislature.

In approving those individuals, we really feel that this is a good marriage and a good relationship between the Department of Healthcare Services that can really focus on providing oversight of the fiscal allocations and the county's use of funding, including accountability for contracted services.

I know you're going to hear a lot about some of the strength and accountability measures that we're putting in this, and it really is the focus on DHCS's responsibility to regulate who they contract with the counties to deliver this care, and for the OAC to really focus on outcomes, high quality programs, best practices, and making sure that we create a marriage between those as part of our agency.

We recently had the opportunity just a few days ago, I think, at the end of last week, to meet with the commissioners, and we're really able to listen and hear some of their concerns about this particular proposal. It was very helpful to listen to their perspective. We want to acknowledge that we heard those concerns and that we look forward to continued discussions similar to what the Mayor Steinberg suggested, that we need to have more conversations, and we are very open to that.

So with that, I will close and open up for any questions and thank.

Thank you, for the flexibility. We will have the remainder of the panel come up. Chair Ting has another engagement and wanted an opportunity.

Chair Ting, thank you, Mr. Chair. Just mish Welsh. I was just trying to understand the problem the Administration is trying to solve by making this Commission part of the Administration rather than leaving it as an independent body.

As I mentioned, I wouldn't necessarily frame it as a problem as well as how we can make it a better success. I think in being part of our agency, there can be more collaboration and integration in real time. Mr. Ewing talked about the value of implementation. We have critical roles in supporting implementation, providing oversight to implementation in real time, and I think it could be very valuable to have that kind of coordination happen in real time together as part of our agency.

How does a Commission that becomes part of the agency maintain its Independence as a watchdog and to provide oversight over the spending?

If I may, Mr. Chair, I think that we've heard that as one of the concerns of this particular proposal, and we hear that loud and clear. And as Ms. Welch and has mentioned, we're happy to continue iterating on this and see if there is something we can do to reach both goals here. Right. Oversight and better integration and alignment. And of course, our goal is always to improve the access of care and improve alignment.

However, what I'm hearing from folks here is that your goals are not being met here, and we're open to having further discussions on what that might mean.

I don't know. It's kind of hard to find a middle ground, I guess, because when we have an independent analyst, our legislative analysts, they're bipartisan. If they worked for either, since we're the majority caucus, we could say, well, they're going to be part of our caucus, but I think the minority caucus would object to that, even though we would say, hey, it's okay. We're going to continue to have it be bipartisan. It's just going to be overseen by us. I'll ask it again.

I mean, how do you maintain Independence and oversight if they are part of your agency?

I don't have an answer to that today, and I'm committing to you that we are going to discuss that and bring it back to folks to consider that further. I don't have an answer to that today.

When I heard Dr. Ewing talk about one of their main issues and when I heard Mayor Steinberg talk about it, talked about a lot of it was lack of data collection, a need for more data collection. That can be done as an independent commission, couldn't it?

In some ways. I think that you'll hear in the later panels or your colleagues will hear in later panels about the efforts that our Department of Healthcare Services is proposing that will have as part of this proposal to increase oversight and accountability. Part of that right now is difficult to share because of the role the Department plays as the contract holder versus the OEC being an independent entity. So there are some pieces of friction there.

I think part of having potentially the OEC as part of agency is because they are brought into agency. There's a little bit more ability to share that information and align that information in real time.

But to me, one of the main roles of this commission is a fiduciary responsibility, is it not? Is there a fiduciary responsibility as per what the voters approved?

I don't know if I can answer that specifically. You might have to get that answer from DHCs. But technically, the DHCS has oversight to the contracts of which the MHSA dollars flow. The way the Mental Health Services act is designed now, it really is driven by the local process. And so as, say, we take Fresno, for example, I think they'll be here later. They get their allocation that comes from the state. They develop their state local process.

Now, the one component that does go to the OAC for review, is currently the innovation component, but for the most part, those are really determined at the local level, signed off by the Board of Supervisors, and then counties are held responsible through the contracts that they have with DHCs.

I'll ask Dr. Ewing, that mean does. If you could just stand at the MIC for 1 second, does the Commission have a fiduciary responsibility? Was it designed as a fiduciary responsibility?

You can join us at the table, Dr. Ewing.

Thank you, Senator Ting. So the law actually states that the Commission has oversight over the children's system of care, the adult system of care, and the older adult system of care, which collectively make up the entire mental health system, public mental health system. But because the PEI language is even broader than that, the Commission's purview is expansive. Our school mental health work, for example.

But when you think of oversight, because you're not managing it, correct. What does oversight mean in your mind?

We actually work to create trust on the part of policymakers and the public, including sharing fiscal information. So some of the very first work that we did was to monitor and document whether or not the fiscal rules were being followed, and including putting online what we called as a fiscal transparency tool that allows policymakers and the public to track MHSA Dollars, spending and unspent funds. And that resulted in. There was a follow up audit. We found about 100 and 9200 $1.0 million of unspent funds.

The Auditor found about 350. So, yes, I would argue that the Commission's jurisdiction does include a fiduciary responsibility, not to ensure that contracts are being implemented in a way that is the way that the Department of Healthcare Services is, but more expansively, much like a grand jury is authorized to look at fiscal issues across a government agency.

Well, to me, a better example, and Ms. Welch, I don't know if you're familiar with, oftentimes when you pass bond measures, you have a citizens oversight bond Committee. Are you familiar with that model, Kim?

I'm not. I'm sorry.

As a voter, have you heard of that? You vote on a bond measure. It's very common. You have a school bond, you have a community college bond, they have a citizens Oversight Committee.

I guess you haven't heard of it. I'm hearing you now, and I understand what you mean.

Very common amongst measures all across the State of California to do exactly what Dr. Ewing said, to build trust with the voters, because the voters want to make sure that money is being spent properly. Now, the districts pick what the projects are. They oversee the contracts they pick, which facilities are being improved, how they're being improved. That's not what the Commission is just making sure that, hey, district, whatever we promised you, it's actually being delivered.

So to me, if the school district proposed to the voters, you know what? We're not going to do an independent oversight Commission. We're just going to have the board of trustees do it. How do you think the voters would react to that? You're a voter. I mean, just tell me how you as a voter would react to it through the chair.

Sure. I think that that's a really important point that you're raising. I think that what Mr. Ewing is talking about is a much more expansive role than that, and I think we could probably have a discussion about a specific oversight role of that that's more akin to a bond. I think, again, reiterating our openness to have this discussion, I think that some of the more programmatic oversight responsibilities that the Commission works on, we think could be improved with better alignment and real time data.

That's why I asked what the problem was. Are you saying the Commission is managing things and your agency is managing things, and because of that, there are too many managers of these programs? I'm still trying to understand what's a problem you're trying to solve.

I think here's a good example. We're going to talk a little bit later about the role that commercial insurance plays in covering the care for individuals. In many ways, a majority of individuals here in our state, we have a number of initiatives underway. One of the things we want to do is really focus on working through the Commission. You're probably going to hear today about many of the good works that they do.

And we really want to make sure that the things that we're working on and that we're pursuing, including just things that are already our responsibility to do, frankly, not necessarily new things that we're doing in coordination with a group that really is trying to do good work and do things like early psychosis and to support the counties to be successful with the implementation of difficult programs.

I don't understand that. So what's the issue that's coming up? You're talking about in the future? We hope to be doing these things and we want to bring the Commission in. What's the issue today?

Our goal is to have better alignment. We think that it can be better.

You think this misalignment, I'd like some evidence of what that misalignment is because you haven't articulated a single example. Sure.

For instance, real time collecting and reporting of data.

Real time data. But part of what I've been hearing, the problem with the real time data is their lack of budget. They haven't been given, we've advocated for years more budget authority, have had challenges getting it to them. So they finally got budget and they're finally collecting the data. Okay, so what else? Seems like we're moving and solving that problem. What other problem do we have that's misalignment?

Well, I think it's clear that you're pointing out the concerns that the Legislature and others have with the.

I'm asking you to tell me where the misalignment is, and you've given me no evidence. I'm looking at data. Give me data. So you said there's misalignment. How has there been misalignment? Please tell me.

We believe that there's misalignment.

But how? Give me a few examples. I mean, you're pure testifying, talking about misalignment, but you have no examples.

I don't have anything right here today, but you have my commitment to come back and share with you that information.

Why did you propose this? Because clearly you proposed it because there was evidence. Or am I to assume that you actually don't have any evidence? And there's another motive as to why you propose this, because you've given this Committee no evidence as to why this was proposed. As of right now, we hear you.

And understand your concern.

So one issue I imagine with misalignment is around communication. How often does your agency meet with the Commission?

Communicate with the only. I will let DHCS speak for themselves, but for myself. We started meeting when I came into this position. I've been in this position for about three years. We meet monthly and I come and spoken to the Commission. I was just there last Thursday. And so I feel like we have a good partnership. My colleague Melissa Stafford Jones, who is leading the Children and Youth Behavioral health Initiative, also meets with Toby and his team right now.

And I meet with DHCS Monthly.

So I'm here monthly Communications monthly. That the communication is good. I'm still trying to understand.

And we have a partnership with the Department of Aging. We released $20 million in grant funds in about six months to a partnership with the Department of Aging. We have a partnership with DHCs around expanding access to early psychosis care through reshaping. And I can give, there are multiple.

Examples of hearing, I mean, what I'm hearing, what I've heard, the only thing that I've heard right this is just me listening. You'd like to get the data faster. I like to get the data faster, too, so I'll totally, completely agree. Seems like you're starting to collect the data, so I assume as soon as you get the data, you'll be happily turning it over to DHCs. Is that a fair statement?

We actually get the data from them? In most instances.

Oh, got it. Okay. I don't know. What data are you looking for, then, if it's your data.

Well, that's the point, is that if they were more brought in, we could get that information to them faster and more real time.

Why? Is it because the email is not working or the servers aren't working, or what's.

There are internal protocols?

Is it like it's a piece of paper or something?

No, I understand your point, and these can sound like very bureaucratic barriers to sharing data, and we can explore what that could mean, but I feel those.

Are your words, not mine.

Sure. I'm acknowledging the concerns that you're sharing, and I hear you, and we will bring it back and are open to continuing the discussion on this particular part of the proposal.

I don't have any concerns. I'm just trying to understand what's the issue. So I'm just listening to what you are articulating. You propose something, you're telling the Committee there's misalignment. There's no evidence of misalignment. So if there's no evidence of misalignment, then there's perhaps some other reason this has happened.

I hear that.

But before we tell the voters that an independent Commission, that is a fiduciary Commission overseeing money be taken away, I would hope that there's some articulation as to why that is as a voter. If someone told me that an independent oversight Committee was actually run by the school board on school bonds, that, to me, is not Independence. So that wouldn't give me, as a voter. I'm just saying as a vote, and I have just one vote on a ballot measure, that would give me pause.

That give me pause. And the fact that we're having challenges really understanding where the money is going from this revenue. How much money is it a year, roughly?

The MHSA.

Yeah, MHSA.

I think it's roughly at this point in time. It does fluctuate dramatically sometimes with our economy the way that it is. But it's around 4 billion.

Yeah. The fact that we can't really articulate where $4 billion is going. It's concerning.

Yeah. As Mayor Steinberg pointed out establishing the Commission was explicitly to support the ballot measure.

Right. But I think one of the Commission's challenges has been not having the budget authority to actually go get the data. Right. Is that correct? Part of it, yeah, part of it. Okay. Well, I mean, we appreciate continuing this discussion. Hopefully we can get a list of what issues we're trying to solve so we can decide whether we agree with this or not. Thank you.

Thank you, Church. We will now continue with the rest of the panel on Issue 16. We are going to begin with Dave Gordon, Superintendent of Sacramento County Office of Education, followed by Bill Brown, followed by Andrea Wagner, and then our students who are here from Imperial County High School, Mr. Gordon and Mr. Brown. Mr. Brown, when you're ready.

Well, thank you and good afternoon. Chair Arambula and Members of the Committee. I am Bill Brown, the Sheriff of Santa Barbara county, and I have served on the Commission as a governor's appointee, representing the state's 58 sheriffs since 2010. It's been such a privilege to serve alongside an extraordinarily dedicated group of fellow commissioners who represent consumers and their families, mental health service providers, law enforcement, educators, legislators, advocates and employers.

Each of our diverse backgrounds is what makes the Commission unique and relevant, and our Independence has provided us the freedom to intensify engagement that influences and touches mental health in areas such as homes, communities, schools, workplaces and the justice system. I would like to thank the Governor and the Administration for their leadership on this important issue. I share the governor's commitment to focusing on full service partnerships and on improving California's behavioral health system to better address mental health, substance use disorders and homelessness.

These are vexing issues which I see every day in my county, and I couldn't agree more that more can and more must be done. Law enforcement officers are often the first responders to mental health crises, and jails and prisons have become a default treatment system. An estimated 31% of justice involved Californians have unmet mental health needs, and the percentage of state prisoners with mental health challenges has increased by 77% over the past decade.

The Commission has been working upstream to prevent justice involvement, reduce costs and improve outcomes. We do that by partnering with criminal justice and behavioral health agencies and practitioners. We have had many important accomplishments in this area. We established data infrastructure to track justice involvement. We documented a 69% reduction in criminal justice involvement for full service partnership participants.

We partnered with federal agencies to identify and observe national best practices to bring to California, after which we published a report entitled Together We Can Reducing Criminal justice involvement for people with mental illness. This report highlights effective ways that counties can better collaborate and combine their resources, provide better crisis services and alternatives to custody for mentally ill people, and expand both jail and community based restorative programs for persons found incompetent to stand trial. We launched an innovation incubator to reduce justice involvement.

We are developing multicounty learning collaboratives to reduce justice involvement, and we are leveraging innovation on a range of projects, including expanding the use of psychiatric advanced directives to improve response to mental health crises, launching a crisis now academy to scale evidence based practices across California, and strengthening county capacities to map the mental health criminal justice nexus. I believe that we are able to do much of this work because of the Commission's Independence, because of our ability to work outside of the traditional boundaries of mental health.

As I mentioned, Governor Newsom has shown tremendous leadership in this field, and that has not always been the case with prior governors. While I applaud his great interest in and commitment to mental health, I respectfully disagree with that part of the administration's proposed plan that takes away the Independence of the Mental Health Services Oversight and Accountability Commission and places it under the Health and Human Services Agency, as well as having the Governor appoint the Executive Director.

The Commission's staff should work for the Commission, and there's a reason for that. My fellow sheriffs and I have been championing efforts to divert mental health clients out of the criminal justice system and to decriminalize mental illness for years. At times, we've had support for that effort and at other times we have not had that support. The Commission was formed in part to make sure that there is a consistent and constant voice to tackle this challenge, among many others.

It is essential that millions of Californians who are struggling with mental health needs continue to have an independent body available to hear them and to recommend ways that we can do better. Mr. Chairman, I thank you and all of the Committee Members for the opportunity to speak before you today.

Next we will have Bill Brown, excuse me. Dave Gordon, Superintendent, Sacramento County Office of.

Education Good evening, Chair Arombial and Members of the Committee. I'm Dave Gordon, Superintendent of the Sacramento County Office of Education and former Superintendent of the Elk Grove Unified School District. I've served on the Commission since 2013 as the representative of local schools. What you will hear in a few moments from the high school students from Imperial County today is exactly what the Commission hoped to achieve when we began advocating that the state move towards encouraging school based mental health.

The Commission believed school entities and health systems could work effectively together to help children to live, work and thrive by partnering to make schools into centers of wellness and prevention and by joining with school leaders to meet students and families where they are, which is in the community. I thank and applaud the Governor and his team for their continued support in creating vehicles to better meet the behavioral health needs of children and youth.

The Governor's historic commitment to the Children and Youth Behavioral Health Initiative is indeed extraordinary, and the Commission's work on School Mental Health was a precursor to that effort. We have been urging our local and state partners to recognize schools as centers of wellness and Prevention since 2016, and the Governor's initiative has the potential to expand those early efforts statewide.

The programs you will hear the students speak about today were developed as a result of leadership coming out of the State Superintendents Association, the CDE and the Commission, among many others, facilitating these strong partnerships between local education and behavioral health leaders.

The makeup of the Commission, with both its behavioral health and education seats, and I want to recognize my public safety colleague, Sheriff Brown in that regard, has enabled the Commission, in its oversight role, to identify and pursue opportunities for innovation that oftentimes go unaddressed in those two important areas. The Commission is currently directly supporting school mental health partnerships in more than 400 school districts and 2000 schools.

We are partnering directly with 57 county behavioral health departments and 50 county offices of Education, one of which is my own. Our school mental health efforts have engaged the Department of Healthcare Services, the Department of Education, FEMA, Community based organizations, University and research centers, among others.

I cannot overemphasize how important this work is, particularly as our schools and communities are struggling in the wake of the pandemic to address suicide risks, addiction and overdoses, bullying and the stress of anxiety from the pandemic and the economic realities facing far too many California families. The expansive perspective of the Commission, which includes suicide SUD services, housing, employment, child welfare involvemenT, justice involvement, as outlined in the Mental Health Services act, has made the Commission's effort even more impactful.

The work is enhanced because the Commission is a small, independent Commission appointed by the Governor that works across multiple sectors in dynamic ways with tremendous flexibility and Independence. In my tenure in public service, working with many public agencies, one characteristic of the Commission that stands out is how nimble it is and how accessible it is to promoting innovative practices and the ability to respond quickly to mounting innovations.

Trying them out, they may work, they may not work, and getting the data to figure out what has happened. And in an area as important as mental health and prevention, that's an aspect of the Commission that I feel we cannot lose thank you for the chance to speak before you this evening.

I want to thank both the Superintendent and Tim Sheriff. We will now have Andrea Wagner, Executive Director for the California Association of Mental Health Peer run organizations, followed by Ivan Arilano, Carlos Castellem and Ayanna Hoffman. If you can come forward, please. We will begin with Ms. Wagner.

Hi, I'm Andrea Wagner and I'm the Executive Director for CAMPRO, the California Association of Mental Health Peer run organizations. As you heard, we represent several dozen independent peer run organizations across the state, which in turn represents about roughly 5000 peer constituents around California.

One of our projects is an MHSOC funded stakeholder grant which we go to all five regions each year and do focus groups among individuals in those counties and people with lived experience asking them what their mental health priorities are and what's missing in their systems of care. We talk a lot. I've heard a lot in the last few weeks from different meetings in the Capitol about data.

And I can tell you firsthand, I'm just about to finish my degree in public Administration from USC and I know all kinds of ways to collect and gather data, but our organizations cannot do that in an effective way and that is the data that states asking for. So when I hear Steinberg saying that there isn't data, how do you collect data on success? When people like me have gotten through the system, through an innovation project?

When I got out of the hospital, that kept me out of the shelter and into housing. I'm not going to the hospital anymore. So my number isn't counted anymore. Right. How do you measure that and how do you quantify tons and tons of qualitative data that we hear every day?

We have thousands of pages of notes of what people have told us and we don't know how to get that to you all because we don't have money to pay for data analysts to come and make fancy infographics so we can show you the success that the voluntary peer programs have provided to our communities. I'm speaking today as a sister of someone with schizophrenia, as a mother of a child that has mental health diagnoses. I've worked in crisis services for five years.

So I've been on both sides of that psychiatric hospital door. I've also been incarcerated. I've also been homeless. I say all that to say that when I first read the Mental Health Services act, it brought tears to my eyes because it was the first time I saw in a legal document the things that made me well and that changed my life and the lives of so many people that I started to meet doing peer work.

I'm concerned about moving the MHS OAC because of so many ways that the OAC allows that open door for advocates like me to come and tell these stories, to be able to talk. And I can say I'm really afraid of it going under CaLhHs based on and demonstrated and outright dismissal and ignoring of the peer community during the care court push last year. I have a really large fear that if this Commission is moved, our peer voice will be incredibly silenced and disenfranchised.

It already is struggling. We already feel like with the Governor and Steinberg and the big city mayors coming after our rights and coming after our programming and our money, and we have no recourse. We already feel know that Goliath is taking the stones away from David. It really feels very much like an unwinnable battle. I remember a couple years ago in this very Committee, we had a budget hearing on this first idea that Steinberg had of modernizing MHSA, and the entire room was packed.

Think you were there? And the public comment was put off till the very end. I was there 7 hours with two people that had physical disabilities. We sat and we waited because it meant so much to us to hold on to the MHSA, and we all stood up at the end. And I think you were the only Member that stayed. And I really want to thank you for that.

And heard all of the public comments that went on for quite a while, and I don't think that anyone else ever probably watched them. And that was really sad. And that's just what we see a lot. And I feel like in the OAC, although they don't always do what we ask, and they don't always hear everything we have to say, it is one of the few places I feel like they're actually asking to hear us, and they actually want to know what we have to say.

I don't know how much time I have, but that's the bulk of what I have to say.

Thank you for that. And we'll say, we are asking to make sure that students have a seat at the table, and we do want to know what you say. And so I'm looking forward to the students who will share their experiences. Next, we'll begin with Ivan Arilano.

All right, good afternoon or good evening. I'm Ivan Ariano, obviously, and I'm here today and telling you guys about my experience with mental health. I guess I'm adopted into a Mexican family. We're known for our pride. But also, what most people don't know is that normally feelings are hidden in a Mexican household. You can't really express yourself in front of certain situations because you'll be seen as weak. You'll be seen as, well, lesser than the rest.

But I've been with that mentality since I was little because I used to try to express myself, or I didn't really know how, so it always come out in the wrong way. And then I finally hit high school and problems started getting worse. My behavior started getting more aggressive. I didn't really care what anyone else thought or felt. I was disruptive, I was destructive, and I wasn't the best person. I wasn't as good of a person as I am now.

And I finally hit my junior year. I moved to, I started going to IHS, and I didn't realize that we had a mental health person there. And I finally started seeing her this year, and she's been helping me through all the problems, my emotional problems and distresses that I've been having throughout the entirety of my life. We've been sorting them out, and now I actually get along with a lot of people.

I am understanding, and I even try to help others with their feelings and their emotions, and I even have a better relationship with my mom and my dad, of course, because they weren't as understanding as they've tried, but I've finally been able to put some sort of understanding into them, and now we can get along emotionally. We help each other throughout problems now. And all in all, it's a very good cause, in my opinion, and I feel like this is something that's very much needed.

Thank you, Ivan. Next we will hear from Carlos Gastalum.

Hello, I am Carlos Gastellum, and I would say, I'd speak on behalf of the students with emotional unavailability, very independent students who I've been going to school by myself, walking miles since the second grade because my mom, middle class, had to work five to nine all the time. I had to take the bus, always alone, just not able to work with my own emotions.

So imagine coming to high school with the reality of adulthood, bills, growing up, and I don't even know how to deal with my own sadness, my own anxiety. I have SATs coming up, I have to graduate, I have to do all of these things, yet I don't even know what to do with my own self, yet I'm told what to do. So with my experience heading into high school, I skipped school, I was a skipper.

I was one of those kids who just, I don't like school, I don't want school, I can't do school. I had to stay home. That's my comfort. Skip school any little way so I can have comfort. Till I got scouted out by the security and they had asked me.

Why.

Were you gone for so long? Months. And I had said, you know what? I haven't told you because I have been afraid that you're just going to tell me, you know what? Just do your work. Just do your work and you're going to be fine.

Like, just do your work. But I want to commit suicide. And right away, every single resource that I could think of was given to me. Every single support, every single resource, everything. I had packets. I had so many people emailing me, telling me that they could help me, so many people calling me, telling me, hey, I got emails by the counselors at the school. I got emails by this and that. I want to help you. Here's an appointment, here's your mom. Give me your mom's phone number. Let's talk.

Blah, blah, blah, blah. Within, I would say, a year and a half, my grades have increased. My relationships with myself and others have just skyrocketed. And I really feel like I've become, like, just the architect of my own life, just the master of my own emotions. And imagine what I could do at 30 years old if I could do this now. So imagine everybody. If every student was like that, then how can it be passed on to their kids?

And what would that look like in the future? So, yeah.

Thank you, Carlos. Next we will hear from Ayana Hoffman.

My name is Ayana Hoffman, and I am a 17 year old junior at Imperial High School. Although I am not originally from California, I come from Montana. I will still be advocating for mental health awareness programs in education systems. Correct me if I'm wrong, but there was a statistic done in 2022 on mental health awareness and mental health services throughout the states, and it listed the amount of how much mental health services a state can give. Number 17 was Montana, and I struggled immensely in Montana.

Number 28 was California. In Montana, I was born into an extremely traumatic, verbally and physically abusive environment. By third grade, I was self harming. If I'm not mistaken, that is, an eight year old to nine year old child. I switched from home to home. Both environments were incredibly traumatic, and by 15, I was kicked out of my house with nowhere to go. Before that, I had been managing my grades incredibly. I was a 4.7 GPA student, always. My attendance was perfect.

I was heading for valedictorian or valedictorian, apologies. And I used schooling as a way to escape from my current situation. I did any extracurricular activities I could. I was an athlete. I was good at what I did. I had incredible relationships with all of my teachers, and I was well known around the school for my intellectual abilities. When I got kicked out, my grades dropped immediately. I was skipping class. I was having more suicidal tendencies. I was harming myself a lot more.

I would skip class if I did attend school to harm myself. I was crying every single period because I couldn't handle myself and my emotions and the amount of abandonment and trauma that I went through with no one to talk to. I had no one. There was no mental health awareness. There was no on campus therapist that could connect me to other resources for my benefit. And I was alone. I had tried committing suicide multiple times. I was sexually assaulted on multiple accounts.

I was abusing drugs and alcohol. I was damning myself. When I moved to California, I had started living with my grandparents, and it has been a lot better. But I was still struggling with keeping up my grades. I was still struggling with going to class and maintaining a positive attitude. I was still crying. I was still having angry episodes, and I was still having intrusive thoughts.

When I heard about the on campus therapist, when I heard about the resources that it could provide me, I was speechless. Never have I ever experienced anything like that. I've never stayed at a school for more than two years, and no school in Montana has ever provided mental health services since then. I have not self harmed in over a year. I no longer abuse drugs or alcohol. I am working through my trauma. I have gotten a diagnosis, a confirmation.

I was diagnosed with borderline personality disorder, and I am currently on medication. My grades are steadily improving, and my relationships with people, my relationships with teachers have exponentially become better. I'm more confident in myself. I can express myself. I am okay with showing my skin. I'm okay with smiling. I'm okay with laughing. And I can finally show people that I am a bright, young, creative, intelligent mind, and I have potential, all thanks to the mental health services that California provides.

I want to thank Ivan and Carlos and Ayanna for your testimony here today. It's important to show your vulnerability, but we see it as strength, and we know the resiliency that's within you will be passed on to other students who are seeing you in these positions, speaking your truth. Because you're speaking for so many students across California, I wanted to make sure to appreciate your time.

Thank you.

We will next hear from Kaleki Ubozo.

Hello. Good evening, Chair Arambula, and Assembly Members. And also, thank you so much for the students and who just spoke to their lived experience. My name is Kalechi Ubozo. I am a suicide attempt survivor, a peer supporter, and someone who deeply cares about the availability and accessibility of self determined, voluntary mental health care for everyone. In 2012, I moved to California, actually because of the Mental Health Services act and the consumer movement.

I was someone who cycled in and out of hospitals and experienced traumatizing care during forced treatment, and I thought I was alone, too. And then I learned about peers, people with lived experience supporting one another. And I heard about this MHSA legislation that not only honored lived experience, funded lived experience recovery, innovation, cultural humility, and so much more.

And so inspired by this consumer movement and imagesa, my mother, my biggest supporter, and I packed up all of my belongings and moved me from Stone Mountain, Georgia to Oakland, California to work in the mental health field. I have facilitated imagesa community planning processes, conducted community based par for innovative programs, and much more. And I'm really, really sad to be here at the corner of what I believe is good intent and truly harmful consequences.

And if you hear nothing else I say today, I want you to hear three things. One, the OAC has to be a separate, independent body or we will lose the voice and expertise of lived experience. Two, changing the target population of the entire behavioral health system will negatively impact the mental health of those who need and deserve upstream care before they have more severe and acute mental health challenges, as literally just demonstrated by the students you heard.

And three, we have to preserve the current requirements for the local funding of PEI component of MHSA, which is actually the most viable funding for reducing disparities through funding community defined, evidence based practices for BIPOC and LGBTQ plus communities. So I will say it's called the Mental Health Services Oversight and Accountability Commission, not the Mental Health Services Act Oversight and Accountability Commission.

And that distinction is important because this body has oversight on all mental health services in the state, which is needed because California does not have a Department of Mental Health. It's also important for those of us with lived experience, which does include peers and family Members, to be able to voice our concerns to an independent body. I'll give you an example.

Since 2018, and more urgently, in response to the devastating outcomes that the pandemic has had on communities of color in particular, and the ongoing effort to reduce disparities, community stakeholders have been organizing to have prevention and early intervention DEI priority. Populations include Tay, who are not in college, and community defined evidence based practices, also called CDEPS. This advocating happened everywhere and also at the OAC, as the OAC creates space for lived experience, not only as part of their leadership, but in dialogue with the community.

So what was the outcome just last week? The Commission adopted those two additional priorities. I'll also give you another example. Prior to the signing of the Governor's Care Court Bill, people with lived experience who may not be in agreement with care court asked over and over again to meet with the Governor and the governor's office to discuss concerns of court order, treatment and voluntary treatment with negative peers.

Collectively did not meet with the governor's office and Care Court was steamrolled through relationship building requires communication and bi directional feedback. And how can we trust that the OAC under the Governor will ensure that lived experiences are heard? We need an independent body to listen to the experience of peers and family Members. And yes, family members and peers continue to wrestle with big conversations, but both of us need to be heard regardless of who is deemed easier to listen to.

We need an independent body that has oversight over the mental services of this state not to be under the Governor because frankly, that is a conflict of interest. We know MHSA is not perfect. When we first started, when counties first started with MHSA, it was like the icing on top of the cake. And now it's grown to be the entire cake. And counties, let's be real, are impacted by politics. And yes, we want more support for folks who are unhoused.

But let's acknowledge that the unhoused population is not the result of mental illness. People with mental health issues are being scapegoated again for economic and social problems that permeate our society. The problem is lack of affordable housing and political will, not people diagnosed with mental illness. With that said, it is my understanding that a comprehensive, multi year study on the California Reducing Disparities Project was completed and showed that CDEPs are not only effective, but have an impressive return on investment.

So one of the unintended consequences of changing the priority populations to focus on who is deemed the most vulnerable and most risk is that we actually deprioritize upstream prevention and early intervention solutions that largely Fund culturally specific and responsive programming, our children and youth programs and our LGBTQ plus programs. We have to remember to see mental health as a continuum that needs more than one time funding efforts, and we need upstream support to ensure that we interrupt increased mental health needs.

My colleague Karis Myrick says it's like we're continually moving deck chairs on the Titanic, but we're not addressing the iceberg. We are not building capacity or looking at our structural efforts. This will have an unintended consequence of harm, which I'm sure nobody wants, and that is not the intent. Thank you so much for listening thank you.

Next, I will have Robert Harris come forward, followed by Tyler Rindy and then Toby Ewing.

Robert Harris with SCIU California on behalf of our 700,000 Members, who paid about a third of what it costs to pass Prop 63, just to be clear. So we have an interest in making sure it works and it continues to work. We don't have a formal position yet on the movement, but when I talked to our Member of the oversight panel yesterday, she doesn't want to move, but we don't have a formal position.

So I was surprised that Daryl was actually straightforward, that it was a political reason that there was an oversight Commission created, because it wouldn't have passed. The polling showed when we were drafting the initiative, it wouldn't have passed without the Oversight Commission. And that's what Chairman Ting was saying, too. It's like people don't trust elected people. I'm just telling you. Okay. Yeah.

Now, public opinion might have changed and they might be able to pass this revision with the Oversight Commission gone, but they might not be able to. And it's true, we have a fragmented system with conflicting rules, regulations, oversight and complex administrative functions around the system of care. And so we waste a lot of money sometimes just in duplicative reporting. But we should remember that whatever changes are made are for the future, for today and the future of people.

And it's not for who's on the Commission now. It's not who they've appointed, it's not for the Governor. They'll all be gone. But hopefully, if we do this right, the MHSA will live beyond all of us. And that's our hope and that's our goal, and that's what we intend to make sure it happens.

Thank you. Next we have Tyler Rindy.

Good evening, Chair Arambula and Members Tyler Rinde with the California Alliance of Child and Family Services. The California alliance represents over 160 different nonprofit, community based organizations providing services to children, youth and families across mental health, child welfare, juvenile justice and education systems. Our Member agencies are serving individuals in marginalized communities that are heavily reliant on services funded by the Mental Health Services Act.

The alliance views the Mental Health Services Oversight and Accountability Commission as a vital partner in oversight entity overseeing the implementation of the MHSA. The Commission provides oversight on fiscal transparency within the act, including if counties are meeting required spending allocations, including within components such as the requirement to spend a majority of PEI funding on children and youth.

Zero to twenty five also releases reports and initiatives exploring prevention and early intervention, criminal justice, school mental health, crisis services for children and young adults, and suicide prevention, as well as approves county innovation plans. The Commission's work on suicide Prevention, set the groundwork for us to work together and sponsor legislation with Assemblymember Ramos to stand up the State's First Office of Suicide Prevention at the California Department of Public Health.

The work of the Commission uplifts specific needs of communities, and the Independence of the Commission, allows them to speak with a free voice, and advise both the Legislature and Administration on issues related to the MHSA. We believe that the work of the Commission has made significant, positive progress to our mental health system in California. The value of the Commission's Independence and importance of its oversight function cannot be overstated, is invaluable for the families and our clients that our Members serve.

We respectfully request that the Legislature reject the administration's proposal to move the Commission under the Administration as an advisory body and instead to preserve its capacity and ability for the Commission to do oversight and to highlight areas that require attention within our mental health system and not be preserved. Thank you for the opportunity to speak today and happy to answer any questions.

Dr. Ewing.

Thank you, Mr. Chair. And Members, just in light of the hour, just really keep my comments very brief and then available to answer any questions. As I stated in the written handout, the origin story of the MHSA is twofold. Well, it wasn't quite stated this way, but it's really been twofold.

It is, as Darryl Steinberg and Assembly Member Ting commented, is that when you put a measure on the ballot with the tax increase, you get a 15% to 20% bump in support, because taxpayers and voters do have an expectation there that there will be a second set of eyes paying attention. But it was also to have a persistent voice on this need to constantly push, particularly in the broad areas of the MHSA, as evidenced by the sheriff and the Superintendent.

The mental health system under the MHSA really recognizes the intersection between criminal justice, housing, education, child welfare, employment. Those are all outcomes that are identified as key priorities under the PEI section. And we are currently partnering with and hope to continue to partner with the Board of State and Community Corrections, the Council on Criminal justice and Behavioral Health, Department of Education, Department of Aging, Housing, Community Development, Department of Public Health, DHCs.

And, you know, one of the questions we have for the Administration as they think about this issue, particularly the idea of moving the Commission under agency, is the Health and Human Services Agency doesn't actually work in some of those areas. And so we're more than happy to continue to strengthen opportunities to partner with the Administration. We welcome that. And as evidenced by the comments earlier, we do meet regularly with a number of officials from the Administration.

But we also would question if it is appropriate to house the Commission under Health and Human Services Agency, recognizing that the perspective that the Commission brings, as evidenced simply by its Members, is broader than the purview of agency.

So thank you for the chance to join you again, and thank you so much for allowing us to support the students to come and talk about the importance of the Mental Health Student Services Act and the Commission's work on school mental health, because that has, as many of you know, that has not been a traditional area of state investment in the past.

And while this Administration has just made historic investments, we hope that continues in the future, and we would want to be in a position to advocate for that to continue under future administrations in the event that that is not a priority. Thank you again.

Department of Finance.

Diana Vasquez with Department of Finance. Nothing to add?

LAO?

Yes, Will Owens. LAO so, to the chair, I just want to kind of set the table so we have a number of initial comments through the remainder of the issue items as it relates to the modernization effort, and we're happy to share those today. Just want to clarify, these are all initial comments, as the actual proposal has not been put forward in language, so any concerns we raise or comments will change over time.

Also, one thing to note, just for the Legislature and the Commission or the Committee, as I'm sure you're aware, to the degree that some of this proposal will be put on the November 2024 ballot, there is time for thoughtful deliberation and analysis on the proposal. This is not something that needs to be done necessarily immediately. So we'd just like to emphasize that, and we're happy to work with the Committee as more information is forthcoming as it relates to the proposed transfer of the Commission to agency.

You've heard a lot today from a number of speakers on the trade offs, and we would like to highlight those trade offs. On one hand, moving the Commission under agency could help better coordinate the state's Administration of its numerous behavioral health initiatives, especially the major investments that have happened in recent years. However, the Commission's existing structure, we acknowledge very much enables the Commission to have a strong independent role in both oversight, policy and research and advisement to the Legislature and the Administration.

There are alternatives to the administration's current proposal, which is to move the Commission fully as an Advisory Committee under the agency, as well as the current structure that the Legislature could consider. An example of this would be the Energy Commission under the Natural Resources Agency, where the Commission would still have Independence for its Members for the Commission membership while still hopefully being able to have better coordination with the Administration.

That being said, with the proposal as it's currently structured, we think the Legislature will want to ask the Administration to provide more information on a number of topics. For example, we would recommend the Legislature ask how the proposal would actually improve coordination of mental health efforts with both counties and stakeholders, and what are the specific outcomes that the Administration hopes to accomplish by transitioning the Commission under agency.

Additionally, we would seek more information on how the transfer would actually impact the Commission's ongoing and current efforts, particularly in terms of staffing, research and development, data collection and sharing, and what the actual result of that transfer would be on those efforts. Happy to answer any more questions.

Thank you. I will bring it up to the dais for members'questions. We will begin with Dr. Jackson. I may ask to create some space for Ms. Welch and Ms. Chen to come forward, if that's okay. Mr. Ewing? I'd stay there.

Dr. Jackson, thank you very much, Mr. Chair, and thank you for everyone who's contributed to this item, particularly our young folks. We want to thank you very much for your insightful words and giving us an opportunity to understand that the things that we talk about really affects real people and things that happen on the ground. And there is no doubt that you have probably had to, you've been up for a while and just know that the time that you've put in today is absolutely worth it.

I would just say that it's important that because this item and the way we've kind of made sure that we've delineated these by issues so that one issue is not spilling into the other in terms of the Mental Health Services act and the Commission, two separate things. And I would agree that the importance of keeping this commission independent, I think, is very important for a few things. As someone who actually enjoys the subject matter, my ability to have frank and open conversations is important to me.

And I think that being someone who is appointed by the Governor, their job is not to be frank and open, just the nature of things. And so I think that it's a public good for this Commission to be independent. Again, how do we ensure that we strike a greater balance in terms of making sure that the state does have a single comprehensive and strategic mental health plan and everyone's moving in the same direction is also essential.

So how do we make sure that we do that in a way that satisfies both? And so I would just urge us to continue to have these discussions, but to also ensure that, like I said, we don't confuse the two. This is a complicated issue, but there is no doubt that the Mental Health Services act was created in a different time. The populations are different.

The needs have grown exponentially, and we definitely need to make sure that every dollar is used for what is best for this moment in time. And so I look forward to the continued conversations. Thank you.

Thank you. And I won't belabor the point. I think you have heard the interest of the Legislature in embracing this portion of the proposal that I'd like to make sure we at least ask the LAO's questions about which outcomes we would expect to see improved if we were to do this proposal.

I diligently wrote down his questions because I do think we owe you a more thorough response, to be frank, than what I can share with you at this very moment. But what I can say is that I think that we do both at the agency level as well as our departments. We really do listen to the Legislature's priorities, too. I've been doing this work for almost 25 years, and it's been really helpful in the last three years to really think about having a shared agenda.

And so I think one of the outcomes that I would hope to see is I think we can do more together, potentially faster when we have a shared agenda and we're all working together. So I know that that's very broad and not super specific. I think we would like the opportunity to be able to do some homework, to come back and give you specifics, but I think there is so much work going on.

You guys know that I've been here in other hearings talking about all the different things going on, and I really want us to be coordinated. We want everyone to coordinate and focus on doing great work with all of the opportunities that we have ahead of us. So that would be the one major outcome that I would want, is the focused, working together approach to get good outcomes for Californians.

If I may, I want to thank the LAO for bringing up different examples. I think that those can be part of the discussion. I think I'm also hearing two different priorities. One in the driving towards goals that we can all achieve, and then the fiduciary oversight in statute, Department of Healthcare Services is the administrator of the MHSA Fund. So how do we square that with what the role of the OAC is? Right.

And so I think that there's a lot of conversations that should be had there when we have sort of a by statute split function already. Right. How do we bridge those two so that we're getting both the fiscal oversight pieces of it and the oversight the policy, broad agenda pieces to it. But here are all the comments, thoughts, frustrations have our commitment to continue the.

Conversation I will elevate while sitting in this chair. I've tried hard every chance I can to make sure the public participates in improving the process, and it isn't always easy to hear the critiques towards proposals, and yet it's an important part of the process for us to get it done right. And I guess I'm trying to understand why we would want to decrease that participation, since it seems that a number of peers and organizations feel more comfortable coming to the MHS OAC.

At least that's anecdotally what we're receiving that I'm trying to understand why we would take that away, as I think it's a vital check and balance for us.

There's no intent to take that away. In my comments, I mentioned many of the duties of the OAC, as they are today, would remain intact, and that is one of the things that they do that's high value and extremely helpful. I did hear some of the comments that some of the other peers made that is irrelated to this particular topic, and I think we'll follow up on.

That as well for Dr. Ewing, if I can. I've loved the work that you've done for the Mental Health Student Services Act. We see the benefit here with students who have received that. That I'd like to understand. Do you think that proposal happens if you have Independence or if you don't have Independence from the Administration?

Do you think that goes forward, or does it only occur because of your connection to community and hearing from those who are at schools about the dire need that our students are facing.

Thank you, Mr. Chair. As we've thought about this, and we've actually had conversations among commissioners, and I think this will be part of our new strategic planning process, which we're undertaking this year, is, there's sort of a couple of models here. One is that the Commission continues to have the sort of portfolio that it has today, and it is apart from some of the other aspects of the Administration.

And there's a lot of value in that because we're small and we can be dynamic and move quickly.

Right. But the downside is, I think, what the Administration is pointing out in terms of the connectedness. And so one example is the work that we did on suicide prevention, where with this Subcommitee really pushed a prior Administration that was hesitant. And so upon the direction of the Legislature and the Governor, that we undertook the process of drafting a strategic plan, which was then handed over to, in collaboration with the Department of Public Health, resulted in the establishment of the Office of Suicide Prevention.

So there's an example of strong connectedness where it was important for the Commission to have an independent voice, to be able to move outside of the domain of what a Governor was willing to do at that time, and to actually have that strong relationship so that it made more sense to put that office within the Department of Public Health than within the Commission itself.

On school mental Health, we have asked the question of who owns school mental health moving forward, particularly given the constitutional separation between our Department of Education, run by a Superintendent, and our Department of Healthcare Services, that is, under the Governor, I don't think it is a good idea to have school mental health owned, so to speak, by the Commission, because we don't have the capacity to manage and grow that space in a way that is comparable to the Administration, as evidenced by the Child and Youth Behavioral Health Initiative.

But that doesn't mean that there should not be a role for the Commission to continue to push in those spaces that are not being addressed within school mental health. Push. There you go.

Push.

That's right. I think it's a very valid conversation to ask this question about how can the Commission be effective at doing things that the Administration isn't doing, and how can we not try to do the things that the Administration really needs to do? And that is a dynamic topic. Right. Because what we know needs to be the focus of school mental health today may not be the opportunity that we're looking for tomorrow. Right.

Five years ago, we adopted a white paper calling for public investment in digital mental health strategies, recognizing that this was taking off in the private sector. But we did not want a subscription based, meaning a fee based, individual, fee based model for digital mental health, because we knew that would leave people who cannot afford that fee. Right. Rural people, people of color. We knew that that would not be where the commercial sector would.

So we adopted a platform that said we have to embrace digital mental health. And in fact, in partnership with DHCS, we worked to actually get FEMA to Fund supports through. So what you see is CalHOPE today, led by the Administration, actually was born out of these early, early conversations because we weren't constrained by having to run a large bureaucracy in a system. It allowed us to sort of look around the corner.

So I believe that the state needs to figure out how it can sustain the school mental health initiative consistent with the three incredibly courageous voices that you heard today. But also be thinking about how can we continue to do better, and that's what we're good at.

I appreciate very much this entire panel. We will now move on to issue 17. Issue 17 is on the Mental Health Services act reform. We will begin with Director Boss. Whenever you are ready.

Hi there. Good afternoon again. Michelle Boss, Director of the Department of Healthcare Services. Since 2019, the Administration and the Legislature have embarked on massive investments and policy reforms to re envision how the state treats mental health and substance use disorder services.

We've invested more than 10 billion, as you've heard over the last few hearings, of investments, children, youth Behavioral Health Initiative, Cal AiM Care act, the expansion of the Behavioral Health Continuum Infrastructure Program and this initiative builds upon what we've already put in place and continues the transformation on how California treats mental health and substance use disorders. One of the key initiatives Key elements of this initiative is the proposal to modernize the Mental Health Services Act.

Today, MHSA funds 30% of the state's mental health system, but the MHSA has never undergone a full scale reform since its initial passing in 2004. The Affordable Care Act and parity laws have significantly shifted the landscape, and now is the time to modernize the MHSA to account for expanded coverage under Medikal.

The governor's proposal includes some reforms specifically requiring counties to dedicate 30%, roughly about a billion a year, ongoing to pay for housing housing interventions and to provide an ongoing source, really, this is an ongoing source for those interventions. Focus funding on full service partnerships as was discussed earlier, by dedicating 35% of the local dollars to full service partnerships and really creating a standardized system of care 30% for community supports and services.

This is where the prevention and early intervention dollars would also come from, workforce and capital infrastructure, broadening the target population to include more people who need support by allowing people with SUD disorders to receive services funded by MHSA and then improve county accountability and increase transparency by updating the three year county planning process to require counties to create really a more comprehensive plan.

So this plan would really bring together some of our independent efforts with regard to the Medi-Cal managed care, population needs assessment work, local health jurisdictions, community investment plan work, bringing all of these efforts together to really what is community behavioral health in a county, instead of really looking at all of these planning processes and these efforts and these programs and these fundings in siloed approaches, what does community mental health mean? And developing a three year plan to do this.

This would continue to build on the local stakeholder engagement process that is very robust under the three year plan under MHSA, but this is adding new players to that conversation. So we have a more comprehensive plan to address community behavioral health. Under the proposal, DHCS anticipates that counties will continue to invest in prevention and early intervention. And really there is a distinction between prevention and earlier intervention and really recognizing some of the population based prevention efforts that we want to be continued to be funded.

We think counties will have more flexibility to adjust their spending as needed, depending on their three year planning process and what the local prevalence and needs of the community might be. This provides counties the ability to flex a little bit in that 35% bucket, really again to identify what are the community needs and how to adjust.

I do want to note a number of prevention and early intervention services are now covered under Medikel and under the newly proposed California Behavioral Health community based Continuum Proposal, the 1115 waiver that is still in draft concept, and also under the California Behavioral Health Children and Youth Behavioral Health Initiative. So now medical covers peer support specialists under medical they were previously not covered prior to the last couple years. The coverage of dietic services, which also was not previously covered.

Medi-Cal Benefit, the community health worker benefit as well, is now a covered benefit in Medi-Cal. And then finally the Children and Youth Behavioral Health Initiative will establish a fee schedule for school based behavioral health services across all payers. If there is a local prevention or early intervention service that is offered but not currently covered by Medi-Cal, this is where counties can continue to use their MHSA dollars to Fund those.

We really want to encourage counties to continue really refining the community defined practices and testing innovative models to build that evidence base to turn them actually into statewide benefits in the long run. I think about community health workers, which were often funded before with innovation dollars. Now that practice has been demonstrated, we have evidence, and now it's a statewide benefit. So want to continue that practice.

I think one of the main reasons to get to some of the questions in your agenda of why counties don't always Bill for Medi-Cal. It does take work to become a Medi Cal provider and want to provide the assistance to provide a path there.

We have streamlined the process for this as well with regard to some of the CalAIM documentation standard revisions, some of the medical necessity criteria, also for receiving services, and then very importantly, the behavioral health payment reform that will go live in July, which also will simplify from a provider perspective, participation in the Medi-Cal health space. I will scoot onto again, our goal here is to really maximize the dollars available in our community behavioral health system.

So wanting counties to Bill Medi Cal and all opportunities possible so that we're able to draw down federal dollars and stretch both MHSA, our realignment and our various block grants to the maximum ability as possible. This proposal does not deprioritize children with mild to moderate behavioral health needs. Many of these children are already being served through Medi Cal, where a comprehensive set of non specialty mental health services are provided through managed care and fee for service system.

Last year, the Department we released our guidance to Medi Cal managed cares to clarify the responsibilities for non specialty mental health services, and we also developed a standardized screening and transition care tools between the two systems between managed care and specialty mental health so that there's a consistent way that children and youth are screened and assessed and transitioned through the different delivery systems.

Again, it's critical that counties maximize all behavioral health funding and avoid using MHSA to pay for services that are actually reimbursable under Medi Cal and really maximize our opportunity to draw down federal funds. In addition, the proposal will align commercial coverage of behavioral health care with Medi Cal. This will ensure that individuals with behavioral health conditions can access appropriate services through their commercial health plans as well, including children and youth with mild to moderate behavioral health conditions.

And then finally, again to mention, the Children and Youth Behavioral Health Initiative will improve access to these critical services in that preventive upstream approach through the virtual Services platform and the fee schedule, which is really maximizing our ability to meet children where they are in schools and provide services and an ongoing funding source for those services.

I do want to reiterate this is a work in progress, as we've already spoken to and we've had many stakeholder conversations and we know we will have many more, but really look forward to the continuing discussion and really understanding kind of where folks might feel there is a loss and getting some specific examples to kind of work through those. Thank you.

Thank you. Next we will have Robert Harris with SEIU.

Them. First, I want to start with a personal and hominem remark, which is, thank you so much, and to the Governor for the Youth and Child Behavioral health thing. I've been waiting my whole life for at least 50 years, so thank you for that. As long as it works, we're good. SCIU knows that a holistic and compassionate approach to care that ensures consumer access to the high quality that Californians need to deal with the range of behavioral health issues. This includes housing, behavioral health help, and supporters.

The whole system of care that's coordinated is reliant on case workers, case managers, navigators, peers, and community health workers who are paid a decent living so they'll actually provide care over continuity. Clearly, there was a mistake in Prop 63, and that was that they only talked about substance abuse in terms of co occurring disorders, and that was because even Mr. Steinberg and no one wanted to deal with the double stigma, and it still exists today.

I was at a hearing earlier this week where they were talking about addicts, right? And it was just grading because it's substance use disorder. It's not addicts. It's not substance abuse disorder. It's substance use disorder. It's a different thing. And so if we could use that to refer to it, I'd feel better. We're happy that you decided to include that. The only thing that we're worried about is because the ODS is pretty much not funded right by the counties, and then they'll fall their own.

The rates are too low. Then you're putting an added burden on the Mental Health Services act to fund something that's already underfunded. And that's worrisome because will there be enough money? And so we're waiting to see the language. The devil's in the details, and we don't know the details yet, although we're getting closer, I think the sooner we see them and understand them and can discuss them, the better we'll feel. And I think the same way goes for the Legislature.

And so, not to speak for you, but, yeah, to speak for you. But once we see them and can work with you and do that, we think we can make your suggestions, probably improve them, we think, and that we'll go forward from there. But it's got to be cooperation, and it's got to be like actually talking about substance abuse disorder.

Schoolchildren, most young people are afraid to talk about they'll get kicked out of school to talk about it, to admit they have problems, and there's got to be a way to deal with that, and so we've got to deal with it. We've got to raise the issue. So that's pretty much it. Thank you very much. Thank you. If you have any questions, I'll be back there.

Next we will hear from Ahmadreza Bahrami, division manager for the Public Behavioral Health in Fresno county, who's appearing remotely.

Good evening, Dr. Ambula. Hopefully everyone is able to hear me. Ahmad Barami, I'm with the Fresno County Department of Behavioral Health. I have a tendency from people who are probably on these earlier panels to know that I speak quickly, so that might be a good thing at this late hour. So earlier in the hearing, Mayor Steinberg noted that the Hmong Community Gardens funded through the county started about 15 years ago.

While that partnership and program was successful, it was eventually sunsetted a few years ago due to feedback we got from two different independent third party evaluations and their fundings and outcome associated with that program. So I just wanted to kind of make sure I set the record correct on that one. We welcome the opportunity tonight to expand on how we're engaging friends, diverse communities.

This evening I will touch on a strong partnership we have with some of our local community based organizations that assist us with doing our outreach and providing services in a culturally responsive manner to one of our specifically traditionally underserved communities here in the Central Valley, and that being our Southeast Asian, specifically Mung population. Fresno County's partnership with the Fresno started with the Fresno center started about 15 years ago. Today, The Fresno center provides an array of community based services targeting our Southeast Asian immigrant communities.

We find these continual services actually through three different components of the Mental Health Services Act. The first one, the Culturally based access and navigation services, or CBaNDS as we Call that an acronym World, is a prevention early intervention funded access and Linkage program primarily focused on providing access and linkages to those in our community, connecting them to those behavioral health services.

The Holistic Wellness center is another prevention early intervention program funded by the Department with the Fresno center that uses culturally responsive approaches such as gardening, dance, traditional healers as a way to engage and have discussions around mental health in a non stigmatizing way that is more effective in engaging those populations who have not been served effectively in the past by the behavioral health system. As a community defined practice.

These services are not necessarily insurance or medical reimbursable services, but they are effective at improving the equity and access for those populations. The Fresno center also operates a full service partnership. We heard a lot about full service partnerships earlier this evening. The Fresno center also operates a full service partnership that's been designed for our Southeast Asian population. That's just one of our FSPs. We do have a number of FSPs here. Fresno County.

Numerous ones that focus on youth, children, justice involved persons, individuals with co occurring disorders, specifically substance use or misuse disorders, as was just noted by the previous panelists, and also cultural specific populations, as I said, with our Southeast Asian population. So I also want to highlight one last program, if I can, real quickly, which is funded through our Innovation partnership with the Fresno Center. It's called the Hmong Helping Hands. I know Chairman of Rambling is familiar with that program.

The Hmong Helping Hands Project was one of the three California reducing disparities projects that was actually ceded by statewide MHSA dollars. Our innovation plan continues to support the Hmong helping hand and two other local CRDPs here in Fresno county with innovation dollars, with our intention to continue those projects as prevention early intervention programs. The Hmong population in Fresno county is made up primarily of refugees and immigrants who came to Fresno in the late 80s, late 1970s, early 1980s.

And we're talking about a population that, when it resettled here in the Central Valley, had already experienced trauma. They had a lot of challenges as far as related to acculturation, and then just does not even count, just the regular mental health challenges that the population has. So they had regular challenges as well as these ones that exacerbated their situation.

Yet from that community, people did not seek mental health services for almost three decades until we started seeing culturally responsive programs begin to emerge through MHSA, through our PEI, through our innovation. That's where we, for the first time, had this underserved community actually reaching out and engaging in services. So I just wanted to kind of highlight that real quickly. And then amongst helping hands, a project works well.