Senate Budget and Fiscal Review Subcommittee No. 3 on Health and Human Services

The Senate Budget Subcommitee number three on Health and Human Services will come to an order. Good morning, everyone. You know, the Senate continues to welcome the public in person and via the teleconference service for public comment. For individuals wishing to provide a public comment, today's participant number is 1877-226-8163 and the access code for that is going to be 736-2834 as always, we are holding our Committee hearings here in the 1021 O street building.

So I ask the rest of the members on the Subcommitee to be present here in room 1200 so we can establish our quorum and begin our hearing. Today, we will be hearing budget proposals from three departments during today, and those departments include the Department of Healthcare Services, the Emergency Medical Services Authority, and the Department of Public Health. But before we get into those budget proposals, we're going to be hearing a presentation.

Well, two presentations today, but the first one is going to be an oversight item, the oversight item, and panel discussion of implementation of recent expansions of Medi Cal Eligibility. We will first hear a status update on these recent expansions from the Department of Healthcare Services, followed by a panel discussion with stakeholders.

Joining us today on the panelists is going to be Cathy Senderling-McDonald, who is the Executive Director of County Welfare Directors Association of California; Sarah Dar, joining us from Zoom, the Director of health and public benefits policy, California Immigrant Policy Center; Kim Selfon, who's also on Zoom, joining us from MediCal and IHSS policy specialist from Bet Tzedek Legal Services; Linda Wei is the senior policy advocate in Western center on Law and Poverty; and Kristen Golden Testa is the Health Policy Director from the Children's Partnership.

And I welcome those panelists who are here in person to join us.

Good morning. Thank you so much, for those who joined us. Here in person and for those on Zoom, let's begin this oversight panel from a presentation, first from DHCs, and then we'll hear from the rest of the panelists.

Great. Good morning. JC Cooper, California State Medicaid Director and Chief Deputy Director at the Department of Health Care Services. As outlined in the Committee's agenda, California has greatly expanded access to Medi Cal Coverage in the last three years, and I'll provide an update on those implementations regarding expanding full scope medical coverage regardless of immigration status. The young adult expansion, implemented in January of 22, has enrolled over 122,000 individuals, which was originally estimated at 90,000.

So we're far exceeding what we were originally estimating, which is great because that means we're getting to people that need access to services. Similar expansion in the older adult expansion implemented in May of 2022 has enrolled over 325,000 individuals, originally estimated at 240,000 individuals. MediCal will also be expanding coverage as proposed in the budget for individuals 26 to 49 implemented no earlier than January 1 of 2024, and we are estimating approximately 700,000 individuals.

We would then at that point have full coverage for all individuals regardless of immigration status in medical, as long as they meet criteria. This is the largest expansion that we have had in the medical program. Additionally, for the elimination of senior penalty for Aged and Disabled program, the ageblind and disabled federal poverty level program, income limits were increased from 100% to 138% of the federal poverty level on December 1, 2020.

CESSA's implementation of the expansion approximately 43,000 individuals that previously eligible with a monthly premium or share of cost now are eligible with no cost MediCal coverage. Additionally, regarding the phase out of the asset test for the non-MAGI MediCal eligibility group, the Department is implementing this in two phases. Phase one, starting January 1, 2022 which has already gone live, we increased the asset limit to 130,000 for individuals and 65,000 for each individual person.

The Department estimates approximately 18,000 new medical enrollees have been implemented since that time, and this is only within the first three months or we're estimating approximately 18,000. We've had 5, 283 new enrollees and that's only with the three months. So still trending very well in regards to outreach and engagement, which is critical, phase two will be implemented in January of 24. The Department is estimating approximately 30,000 new enrollees will be eligible for mattel due to the elimination of the asset tests.

We have already issued guidance in November of 2022 on phase two and is currently working on the state plan amendment that we would submit to CMS for that approval for January 1, go live. Additionally, we sent out direct outreach letters to individuals previously denied for being over the asset limit, encouraging them to reapply to medical so they are informed in regards to the changes of the expansions that we are implementing.

We will also be working with our communications vendor that we have brought on for the public health emergency to get the word out to everyone in regards to these transitions and expansions that would include the asset limit expansion as well as the full coverage for all individuals. We'll also be working very closely with our navigator or health enrollment navigator programs across the entire State of California.

We were asked to flag some of the potential operational challenges at the end of the public health emergency and the redetermination process may bring to this various coverage requirement expansion and how we are planning to mitigate those challenges. In order to ensure that individuals that were brought on young adults that would be otherwise aging out, we did deprioritize the annual redeterminations for individuals that would have otherwise aged out to January so they could have seamless coverage once we expand to undocumented individuals 26 to 49 so they would have seamless coverage.

Additionally, submission was just submitted to CMS for essentially a waiver that would allow us to continue individuals who otherwise would have lost coverage because of the asset being over 130,000 since we are eliminating it in January of 24 to maintain coverage through that time period, and we would then have full elimination of the assets January 1. So we are trying to make sure that people would not lose coverage, that they will maintain coverage if they would have eligibility on January 1 of 2024.

We are confident with many conversations we've had with cms that they will most likely approve that, but that is still pending CMS approval and we are very excited that we were able to find a solution for that moving forward so we can continue coverage with people that need that service. Also, due to the sheer volume of policy changes coupled with the huge work that will come under the public health emergency, DHCS has taken many steps to ensure that we are as ready as we can be in California.

We have requested multiple federal waivers to simplify the redetermination process, to simplify the number of touches our county partners will have to take and or to streamline whether it's ex parte, which is essentially a fast stream enrollment or redetermination process, to do things. We've been working on trainings with our county partners, readiness plans with our county partners, and extensive technical assistance to be ready for the redeterminations coming before us in April of this year.

And so we look forward to continuing to working with our county directors and CWDA on this very large movement. There are also two coverage expansion initiatives that were approved in SB 189 last year that are subject to a spring 2024 determination. That General Fund over the multiyear forecast is available to support ongoing augmentations and actions. They are the share of cost reform, increasing the maintenance levels and the continuous coverage of children zero to five years of age.

Regarding the changes for the calculations of share of cost for medically needed older adults in persons with disabilities. This change will lower or eliminate the share of cost for individuals in certain medical programs and will potentially allow a greater number of individuals in these programs the ability to meet their share of cost each month. This proposal will also allow these individuals to keep more of their income to pay necessities while allowing them to access medical services.

The Department estimates that approximately 28,000 medical members would transition from having a share of cost to no longer having a share of cost, and approximately 91,000 medical members would have a share of cost reduction. The state is working on a state plan amendment, obviously, that is contingent upon appropriation in next year's budget. The continuous coverage for children zero to five provides continuous coverage by disregarding all income changes to the child and without any redeterminations until they reach the age of five.

DHCs is looking to the policy design of Oregon, which recently had this approved by the Federal Government as a baseline in regards to how they're designing. We've been having conversations with them and CMS to prepare for this design. DHCs assumes that 64,000, a little over 64,000 children would remain covered in medical that would otherwise be the case if absence of this policy. This type of change, though, does require a section 1115 waiver from the Federal Government, which has a pretty detailed process.

The Department is committed to stakeholder engagement in working on an engagement plan to review and vet policy design later this fall in 2023. However, while the Department will kick off stakeholder engagement later this year, official submissions of any waivers or state plan amendments to CMS will be subject to a spring 2024 determination that General Fund over the multiyear forecast is available to support ongoing augmentations and actions.

However, what I would say is the Department is very committed to that stakeholder engagement, and we do it for all expansions, including the ones mentioned previously, where we work very closely on program policy design, outreach materials, we work on system changes, we provide technical assistance to our county partners, all things that are needed to make sure that we have successful implementations.

And as you can see by our track record where we have expanded Medi Cal Coverage, we are far exceeding our various expansion numbers in every expansion that we've done in the last few years, which means the process we've been working on, engagement with our locals, with our county partners, and with our advocates is working, and we are excited to potentially engage in those other two expansions that are coming before us next year. Additionally, there were some questions around the systems.

DHCs and many of our partners have been going through a massive migration of systems in the last few years. We are excited that this will be eventually coming to an end, and really, we think once it is, it will obviously be very, a lot easier for us to implement systems in one system across. However, we do just want to flag for people any changes around expansion in various pieces. We'll always require system changes, which takes design, testing, configuration, technical assistance to our county partners.

And so we will always need a nine to 12 month Runway for any medical expansion just to make sure we have time to engage with our advocates, to engage with our partners, and to implement successfully. So happy to answer any questions when the time is right.

Thank you so much. We'll move on to Cathy.

Great. Thank you, Madam Chair, Senator Dodd, Cathy Senderling-McDonald, I mean, Senator Roth, sorry about that. I was watching Senator Dodd earlier in the Senate. Yeah, thank you, sir. So, Cathy Senderling-McDonald for CWDA. I was asked to answer a few questions as well. So the first question was related to from the perspective of county eligibility, how have the expansions impacted our volume and the complexity of our eligibility workload? First, I want to say that counties have welcomed and supported the eligibility expansions.

We're glad to see the increase in uptake to the Medi Cal program and the eligibility changes for undocumented individuals as well as seniors, persons with disabilities and young children. The expansions have definitely come with workload as they have both increased our caseload and made some changes to the program rules. So counties have updated training materials so that our eligibility workers know about the coming changes and how to implement them.

We need to make operational changes when things like this happen so we can address the increase in applications, making sure that we've got systems in place to monitor that, and also the increase in ongoing case management work that it requires. And then at times we've had to perform manual workload as we're waiting for everything to get fully implemented to ensure that individuals in the expansions are going to continue to have Medi Cal Coverage, especially as related to the last three years, the pandemic and the continuous coverage requirement. We've worked very closely through all of the steps to make sure that as we've expanded, we've not dropped off people erroneously as the continuous coverage requirement has been in place.

So it is also important to note eligibility work isn't done in a vacuum. We also, of course, administer Cal Works and CalFresh on behalf of the state and Federal Government. And so our workers are often trained to perform eligibility functions across one or more of those program areas.

And so expansions just in one area can also affect the work that they do elsewhere because we have to think about how the programs work together and make sure that the worker who's cross trained understands those interactions and can watch out for those as they're implementing so they don't accidentally affect the case on a CalFresh case, for example, when they're making a change in Medi Cal. Overall, though, we feel like they've gone well.

And as you heard from Ms. Cooper, the numbers seem to indicate that we're in the right direction with the expansions. We were also asked to talk about the resources that we've received for the expansions. Are we well resourced, and how does that also interact with the unwinding of the continuous coverage requirement that we're going to start, as you heard and know doing in April.

I'll say in General, counties have been more adequately funded for Medi Cal eligibility than we have in recent years for the other two programs. And we'll talk through the budget process about issues that we've got in the CalFresh space as well as in the Cal Work single allocation. However, I will say that we've identified a couple of recent issues, especially with the way in which the Administration is calculating our annual cost of living adjustment that we are growing more concerned about.

So I did just want to put this on your radar today. It's a technical issue, but the bottom line is that the Administration hasn't been using the most updated CPI numbers, the cost of living index numbers, to adjust that amount that we received, that we receive each year. This occurred in the current budget year. Remember how inflation really spiked very high at the beginning of 2022? Unfortunately, we didn't see funding from that because of the way that they had calculated the budget.

They were still looking at an older number and it was not updated for that higher number. The difference was $46 million. This is a big program and we do receive a significant amount of funding across 58 counties and 15 million recipients in order to administer it. And so a few percentage points can translate into a significant amount. And the issue is that counties do actually need to absorb those costs. I mean, we were experiencing inflation just like everyone else has been.

And so it was a difficult conversation last year to try to figure out how do we adjust, maybe the methodology going forward. And I'll say that this year it does seem like timing continues to be an issue that we're again not seeing the same CPI increase that other aspects of the state budget, not just in this Department, are.

And so we'll be engaging with the Administration, but also wanted to put on your radar that we're seeing another issue again this year and that we are concerned about that. So we're hopeful that we can kind of nail down the process and get it to be more up to date. My staff have experience with working in the Administration and know kind of what the process is for updating that, and so we'll be talking with them.

But we are concerned that it's not a really great time to be kind of nickeling and diming the operation when we're about to start the redeterminations for 15 million people, many of whom we've not worked with for a really long time. So I definitely wanted to get that on your radar. We really appreciate the agreement that in our program we get a cost of living adjustment. Not every program does, but making sure that it actually reflects the actual cost increase would be helpful.

I also wanted to let you know that we are requesting from the Administration a one time increase of $44.5 million General Fund to cover county staff time associated with anticipated hearing requests that we anticipate getting. When someone is discontinued or has adjustments that are detrimental to their coverage, they can request a fair hearing, and we want to be able to be on hand to help with that process. Counties do have staff that are dedicated to that.

They cover also, though Cal Works, CalFresh, IHSS, child welfare, the whole gamut of the programs that we run. And so we know at the state hearings level, they're looking at whether they need additional administrative law judges to handle the anticipated influx from an estimated 2.8 million people potentially being discontinued, partly because they may not respond, partly because perhaps their income has gone up. We hope that it's a lower number, but certainly we would anticipate some of them to ask for a hearing.

So we'll be talking again with the Administration about that, but also wanted to put that on your radar as well. The third question that I was asked to address was related to the outreach that we've done for the expansions that you heard about. I would say that counties really appreciate the outreach work that the state and our community partners do to make sure that the newly eligible populations are aware of the opportunity to apply for Medi Cal coverage, as you heard, for example, the notice to people who'd been previously denied because of their assets.

Knowing that that rule is changing, we work very closely to coordinate, to know when messages like that are going to be going out so that we can alert our workers, even counties folks at the front desk who might be hearing about this so they know that that's happening. We also use resources that are produced by DHCs, as well as our counties and other organizations such as posters and flyers, and often those are translated where they need to be into the threshold languages as well, so we get good outreach and coverage. In addition, counties can publicize eligibility expansions on our websites and on our social media pages.

A number of our counties are very active in social media and so they will do that kind of outreach as well because they know that people check Google and kind of see what's going on in the programs and then they may come in accordingly. We also work very closely locally with our local organizations. And then finally we were asked to also address the calsaws question related to eligibility changes and how we do have that lag.

As Ms. Cooper was noting, when we get an eligibility change, and that the hope is once we get migrated over to the CalSAWS and have 58 counties in CalSAWS, which we do anticipate in January 2024, is it going to be easier to implement? I will say it is definitely the case that the federally mandated move to this single system has taken up a lot of the bandwidth for system changes, eligibility, expansion, programming, and changes across all of the programs that are within the system and really limited our ability to make these changes as quickly as any of us would want. So those impacts will go away when the migration is complete.

We do want to note that the Federal Government didn't allow a lot of changes to the underlying system, and so there will be still some lag because it takes time to automate and our system. All of our programs that we operate, CalFresh and CalWORKS, as well as Medi Cal that we're talking about today are really highly automated. And so most changes, if not all, do require some level of automation and the workarounds can be very difficult to do manually.

So what we do is try to provide that input as you all through bills or the budget process are thinking about changes. To say, this one is bigger than a bread box, this is going to take a while, or this is one that it looks like we could make a relatively quick change, or maybe there's even a manual workaround that we could do in this case.

So we want to be there and be that resource in order to be able to give you honest feedback and information as you're considering certain changes so that you know how long it would take. The other thing to note, too, is that it is important that we coordinate very closely, as Ms. Cooper noted, on the stakeholder input, and get final instructions to our IT staff before they start to program.

The reason being many, many years ago, decades ago, when we first automated everything and kind of started going, sometimes the systems would get going on changes and things wouldn't really be finalized yet, and then changes would be made and they'd have to stop and kind of go backwards, and it took longer than it needed to. So now we do have an agreement that we really need that final in order to be able to proceed. And so all the policy questions, which really the policy should drive, the automation, it shouldn't be the other way around.

And so we work really closely to try to put county staff on those groups, our team on the group stakeholders like the ones you're going to hear from today to make sure that we're really hammering out those questions so that when we get that instruction and we hand it over to the IT folks, it's final and we can get going and feel confident that what they're starting to program is what they really need to program to make it work. So I hope this has been helpful and, of course, happy to answer questions at the appropriate time.

Thank you so much, Cathy. We'll hold questions until the end of the last panelists, we're going to move on over to our zoom panelists, Sarah Dar, who's the Director of health and public benefits policy at the immigrant Policy center. Welcome.

Hi. Good morning, chair and members. Thank you so much for having me today. So I've been asked to speak to the medical expansion for undocumented individuals. CIPC, the California Immigrant Policy center, has actually been in the process of reaching out to our grassroots networks to seek input about how to be best prepared for this expansion and what they anticipate the greatest challenges being and best practices for getting around those. And so I'd like to share some of our key takeaways and what we've learned so far.

And these are all considerations, I think, that the state can keep in mind when thinking about how to do its own outreach and how to best support CBO partners that will be on the front lines of getting the word out about this expansion and making sure that people are enrolling.

So some of the things we've learned in our conversations with our partners who are well connected in these newly eligible communities is that it will take one on one contact with trusted messengers and one on one enrollment assistance to reach and enroll people who are undocumented. Face to face is much more preferable than other methods of trying to get in touch with people. In some parts of the states, these trusted messengers that do have the deepest reach and relationships in these communities may not necessarily be enrollers themselves. And so they're very willing to do the outreach. They have the capacity, they have the reach and trust in these communities, but will need to be connected to additional partners that can provide enrollment assistance.

And a lot of them had said that the most ideal thing would actually be to bring enrollment assistance partners on site to where they do their work and to be connected to those to help them. They can be a bridge to connect that enrollment assistance directly to community members. Obviously, these groups need additional resources in order to do this work, and a lot of the issues that their staff are dealing with include just burnout and a lot of capacity strain, and particularly in retaining people with language skills, as that's going to be a huge need. So it may take time to build up the capacity for all of that work.

As always, language access is a major barrier to enrollment and to even just knowing about the medical expansion, particularly for limited English proficient people who are AAPI or indigenous. Work schedules and transportation will make it very difficult for many people who are undocumented to enroll in Medi Cal and subsequently seek care. Common types of work that some of our grassroots partners have shared with us that the communities they work with are engaged in include farm work, domestic workers, home care workers, warehouse workers, and day laborers.

There are CBOs on the ground who have very successfully found ways to meet all of these individuals at their homes or places of work or other gathering points in the community to do other types of outreach and service provision and community education. So a lot of these CBOs dropped everything to do Covid outreach and to just take testing and vaccination on site at places of work and other places like that.

And so they have the infrastructure to sort of reach these people and they could be deployed. This infrastructure could be deployed to educate communities about Medi Cal. But however, as noted earlier, they're usually not equipped to do enrollment, and so they would need enroller partners on site or some other way to connect and do a warm handoff to an enrollment assistor. The transient nature of the jobs many undocumented adults have could also make continuity of enrollment and access to care a challenge.

So people might be working in different counties at different times of the year, and that presents a challenge, obviously, for the obvious reasons, because of Medi Cal being administered at the county level and people having to change their case over from county to county. That's something I think that the state should just anticipate, be prepared for, and figure out how to reduce that type of barriers to that type of moving around, impacting people's continuity of care. And for some people, it's even crossing state lines.

There are transient workers who might spend one part of the season in California and another part doing agricultural work in Arizona or somewhere else. So these are just things that I think we can hopefully try to find workaround so that it doesn't disrupt people's ability to get care wherever they are. Groups that enroll people. So we did speak with both grassroots organizations that have really deep reach into these communities that don't do enrollment, but also we did speak with enrollment organizations as well.

And a lot of those organizations are the ones that, again, particularly work with undocumented communities, as many navigator and enrollment organizations don't, or a small number of the clients that they serve are undocumented. But there are some who really specialize in working with that community. And for those organizations, they are used to how difficult it is.

They've come up with their own workarounds, and many of them told us that they think it would be almost impossible to imagine anyone who's undocumented applying without some type of one on one assistance. So again, just the need for direct assistance is going to be huge and potentially an insurmountable barrier to actually getting enrolled if people don't have someone they can sit down with.

And that's challenging in a rural part of the state or a part of the state where there aren't as many CBOs or assistants around, and especially for, again, people who are in lines of work where they can't take that time off to go make an appointment and sit down in the office of their local CBO. So just thinking of ways to sort of reach people where they're at, and then obviously the enrollment process is challenging.

Documenting identity, income and other elements is really difficult without that individual help from an expert enrollment assistor. So this might look like people having, I don't have a weekly pay stub. I get paid varying wages every week, and it may be under the table or in a way that's hard to capture or document. And so what is my monthly income? I don't know. It fluctuates, right. And there are ways that enrollment assistors know how to calculate that, come up with averages, et cetera.

But people need that type of guidance on how to do that. Same thing with, as you can imagine, trying to provide information about your identity, even sometimes where you live, can be challenging if you're moving around. So gathering all of that information and figuring out the best way to provide all the necessary documentation is going to be extremely challenging and require, again, dedicated one on one assistance for people.

Some of these enrollment organizations mentioned that their counties are working very well with the CBOs there, and that's helped reduce barriers and lighten the load on CBOs. Others have not had that experience. So I think what all of this goes to show is just that there's a need for the state to, I think, have more of a focus and capacity and resources dedicated to outreach. And that may not necessarily be the state and counties doing the outreach, although that's part of it, certainly.

But it also means much more robust support, engagement and capacity and resources for CBOs that again, are already meeting these individuals, doing community education, providing services and reaching them. Many of them have said, we just picked up some medical applications and took them out once the young adult and older adult expansion pass, we honestly don't know the best ways to fill out this application, but we're just trying our best to sort of make sure our communities are aware. We don't want them to miss out.

So the work is being done and people are willing to do the work, but there's just some support needed in terms of technical assistance, enrollment assistance, and connecting the groups that have the reach into the community with the groups that have the skill set to get them through the very complicated application process.

And then I've hardly even touched on all the issues once people are enrolled and all of the support that could potentially be needed to make sure people are understanding what it means to have coverage and utilizing it. And so I don't have a specific amount of dollars that I'm recommending be allocated or anything like that.

But just as the state is moving closer and closer to this implementation date, I would just encourage that the state really think about increasing opportunities for, whether it's navigator funding, whether it's just any sort of training and technical assistance, any sort of opportunities to help these CBOs build up the capacity to do the work that they're so well equipped to do if they just had some support, because it's just abundantly clear that this is not a community.

I mean, if we all understand in most cases has never interfaced with the healthcare system before in any way, never given their information to the government for a public benefits application or the like, there's just so many barriers and it would be really a missed opportunity not to take advantage of the CBOs and the infrastructure that's already reaching these communities and just use that as a conduit for getting out information about MediCal. And that concludes my remarks today. Thank you so much. Happy to answer questions as well.

Sarah, I really appreciate that. And I want to echo that. I used to work as a Director and nonprofit, a CBO in my district that works with predominantly monolingual Spanish speaker, predominantly Filipino individuals. And we helped during the COVID rental assistance and other public benefits. Right. And the number one thing that we would hear, we physically help people fill out the application was that it was so daunting. It was language barriers.

We can say you press Google for change of language as many times as we want. It's still a barrier. There's technical words within. And we saw a huge increase in people wanting or feeling comfortable to apply because they sat next to someone who really walked them through that. So I just wanted to echo that. So before we go on to the next panelists, if we can establish a quorum, please.

[Roll Call] We have a quorum.

Great. Thank you so much. We're going to move on to Kim Salfon from the Medi Cal and IHSS policy specialist. Thank you so much. Welcome.

Good morning. Thanks for having me here today. My name is Kim Selfon. I'm an advocate at Bet Tzedek Legal Services. I appreciate the opportunity to allow me to speak today. I've worked at Bet Tzedek for over 20 years as a Medi-Cal advocate serving the LA community. My clients are older adults who are severely impacted by disability and need help with their activities of daily living. All my clients are on Medi-Cal and IHSS.

I can't express how excited, like truly excited advocates are with all these Medi-Cal reforms. They improve the health and well-being of older adults in our community and people with disabilities who now have greater access to Medi-Cal. I want to thank the Department of Healthcare Services and the Legislature for these historic Medi-Cal investments. Today I'd like to address several challenges I see in accessing Medi-Cal for the population that I work with.

We all know that Medi-Cal asset limit changed from $2000 to $130,000 in July. However, this seems to be a closely held secret. Almost all my clients are unaware of this monumental change. The people most surprised are Medi-Cal participants who had no idea the law changed. One woman I spoke with has not collected a $12,000 life insurance policy because she didn't want to lose her Medi-Cal benefits. Another woman was happy to learn she can finally start saving for a power wheelchair.

The asset limit increase is almost meaningless when people don't know about it. It's vital that current Medi-Cal recipients are informed of the asset limit change so that they can benefit from it and save for the future. We urge the Department of Healthcare Services to follow through on its recent commitment to send a mailer to current Medi-Cal participants and inform them of this wonderful change to the program.

We hope the department can commit to a time frame to send the mailer and a stakeholder review process. Let's spread this good news. Looking to the future, I urge share of cost reform be implemented. The share of cost base level must be changed from $600 a month to 138% of federal poverty level. I ask each one of you, could you live on $600 a month to pay your rent, your utilities, your food, your phone, your other bills? It's impossible, you say.

Well, that's exactly what Medi-Cal and California requires of older and disabled adults in the medical share of cost program, they are only allowed to have $600 in income and the rest must go towards their monthly medical share of cost. No one should have to live on $600 a month, especially our most vulnerable citizens. Changing share of costs to 138% of federal poverty level is an equitable remedy to our current inequitable system. Finally, we're concerned about the end of the public health emergency and potential medical terminations.

Many people have moved since 2020 and have not updated their addresses with Medi-Cal. A client emailed me in January stating, quote, I have been trying to Medi-Cal for days with no success to change our address and phone number. Every time I call, after a 30-minute wait, the message says they're too busy and to call back later and I'm disconnected. I did find a Medi-Cal contact update form, but it had no mailing address.

She was proactive, but she could not overcome the barriers to complete what should be a simple task of changing her address. I'm concerned people will be terminated because they could not update their addresses or contact Medi-Cal to provide other necessary information. We suggest a safety net be created to catch people whose Medi-Cal services are terminated. Some options are counties could create a dedicated phone line to assist with Medi-Cal terminations. Only.

These calls should be prioritized and people should have an option to leave a message or call back because people can often not get through on the customer service line in LA, and I know that's not just specific to LA County. Counties could create specialized workers to assist in curing the Medi-Cal termination cases. And in order to quickly reinstate eligibility, counties should encourage workers to allow people to submit Soren statements over the phone or online, which eliminate the delay of providing documents through the mail. We must protect our most vulnerable citizens from losing vital health care. We appreciate your partnership and look forward to our continued work together. Thank you.

Thank you, Kim, for sharing that. Moving on to our next panelists, we have Linda Nguy from the Western Center on Law and Poverty. Welcome.

Good morning, Chair. Members, Linda Nguy with Western Center on Law and Poverty. Firstly, we want to commend the administration and the Legislature's recent Medi-Cal expansion that will make California the first in the nation to cover all low-income adults, regardless of immigration status. Together with the end of the senior penalty and the scheduled elimination of the asset test, all adults under 138% of the federal poverty level will be eligible for free full-scope Medi-Cal effective January 2024. Enrollment into full-scope Medi-Cal is easy for some.

For example, the department sent mailers to people who were denied Medi-Cal due to being over income or above asset, inviting them to reapply. The department also automatically moved young adults and people 50 and older from restricted emergency scope to full scope. But as great as these enrollment pathways are for some, more is needed. Many low-income people aren't aware of these expansions, they assume that they aren't eligible, so don't even bother applying for Medi-Cal.

The asset test is a decades-old rule that before July remained unchanged despite inflation. So when the asset me so when the asset limit increased, we expected a much larger group of individuals to be newly enrolled. Ms. Dar highlighted the need for trusted partnerships to outreach for health for all expansion. So we'll also share the need to update some forms. For instance, the MC 13 form still uses the term aliens, stating that only those aliens with satisfactory immigration status are eligible for full-scope Medi-Cal.

This is despite the not-so-recent expansions to individuals, regardless of immigration status. With the implementation of all these expansions, the Medi-Cal of 2024 is not the Medi-Cal of past. This should be celebrated and publicized, so urge the department to widely share this news through outreach and partnerships with community-based organizations. Existing resources like the $25 million contract with outreach vendor GMMB for unwinding could also encourage people to sign up for Medi-Cal. We recommend the department explore sustaining the campaign beyond May 2024 to encourage continued enrollment.

I also want to publicly thank the department for its work to minimize coverage interruptions for seniors and persons with disabilities once renewals resume this April and before the asset test is completely eliminated next January. Without this, many seniors and persons with disabilities would have had their Medi-Cal terminated for failure to verify or for being above the current asset limit.

However, coverage termination concerns remain. Advocates from across the state, Alameda, Santa Barbara, LA, and Sacramento, to name a few, report county call wait times in excess of 30 minutes, disconnects and drop calls, and other barriers. This is prior to unwinding and before the expected surge in call volumes. We worry that individuals will be terminated not because they are no longer eligible, but because they cannot report their new address change or other changes.

LA County call abandonment rate averaged 20% last year, meaning over 100,000 people a month got tired of waiting and hung up. Even worse, an additional 150,000 calls per month were simply disconnected because call volume was too high. It's unclear how many people gave up completely or tried again, but this demonstrates a discouraging process that is expected to become even more challenging.

We appreciate federal guidance requires counties to check other sources like the Medi-Cal plan and require contact beyond mail, but we fear people will lose their Medi-Cal even though they did everything right, including trying to proactively contact the county. In light of county office staffing shortages, the county computer system's automatic cutoff feature looms large.

Basically, if a case is not touched, then the Medi-Cal will automatically end when counties are overworked and there's no guarantee that submitted renewal information will be marked as received in time. Thousands risk erroneous terminations due to the auto-termination functionality. We recommend safeguards to protect Medi-Cal enrollees from being unduly terminated. There needs to be some sort of halt function when Medi-Cal cutoffs exceed expectations, as well as data measurements in place to know when to stop terminations. This may include monitoring call center volumes, requests for state hearings, volume of terminations, county staffing, readiness reports, and more. Bottom line, given the current difficulties, the department should be planning for a safety valve. Thank you.

Really appreciate that, Linda. And our final panelist is going to be Kristen Golden Testa from the Children's Partnership.

Thank you. I'm here to talk about the multi-year continuous coverage proposal for children. We're very pleased that California has enacted this policy. The evidence is quite clear that stable coverage is going to increase well-child visits, dental care, and better health outcomes. Conversely, gaps in coverage are going to lead to delays in care, unmet need, and risks of hospitalization. The aim of this policy, and when it was implemented, was intended to continue to protect children when the federal continuous coverage proposal ended.

The absence of the continuous coverage proposal will mean that about 800 to a million children will be losing coverage during the unwinding. This is a great risk and a big step backwards in our enrollment. Oregon, as you heard, has already adopted and is going to be operating its continuous coverage proposal so that it will seamlessly back up on the unwinding that they're going through so that children will not have to lose coverage.

Unfortunately, California is not on track to be able to be prepared to implement the continuous coverage when DOF gives the green fiscal light to do so in 2024. In last year's budget, DHCs had said that there were some lengthy preparations necessary. One is to submit 1115 waiver, two, as you heard from Kathy, is the county guidance in developing that policy, and three is the lengthy automation time it takes for the system changes.

We are deeply concerned that the department is not doing these preemptive, pre-implementation steps to be ready to go live when the Department of Finance gives the fiscal green light in spring of 2024. What we're hearing, and you heard in the testimony that they are waiting until the Department of Finance offers that before starting with the waiver, we have been urging them to not delay.

In fact, it was very clear in the budget law that there was supposed to be this is the trigger language in the budget language. It says that you're supposed to be supporting and preparing for these future programs. And so we're asking that the department expedite the preparation so this policy can go live when we get the fiscal green light from Department of Finance. And we continue to urge them to immediately begin these lengthy pre-administration planning parts.

For example, we want the waiver to be submitted as soon as possible now to have conversations now on the policy development, given the length of time it takes to implement them. And then also, as you heard, it's a very lengthy process for automation system modification. So we'd like to begin that process of planning as soon as possible. And we urge the Committee to instruct the Department to start those pre-planning preparations now.

There are several things that can be done in order to make it as seamless as possible with the unwinding and children not falling through the gaps. You've heard that there was an approval from an E-14 flexibility waiver for other populations. We hope that California will consider that for children, that would include deprioritizing young children's applications or renewals so that it could be at the further end of the unwinding period and hopefully in time for, if prepared in advance, the implementation of the continuous coverage proposal for kids. It really is a critical time for children.

The reason why this policy is directed at children, young children, is because in those first few years of life, 90% of their brain development is occurring, and small gaps in coverage can be very disruptive because children before the age of five have about 14 well-child visits and screenings that occur in those times.

We know that continuous coverage can make a big difference in making sure that the gaps, that they don't have as much gaps as we've seen in the last few years of the federal continuous coverage proposal, that it has reduced children's gaps in coverage by about 75%. And we hope to protect those children by asking that the implementation and the preparations are happening right now to prepare for our continuous coverage in California. Thank you.

Thank you so much. Before we turn to questions up here, would like to ask LAO or Department of Finance if they have any comments.

Luke Koushmaro with the LAO. We do not have any comments for this panel but are available for questions.

Great.

Thank you.

Department of Finance. I welcome you up.

Hi, Atitio Valetti, Department of Finance. No further comments at this time, but welcome questions.

Great. Thank you so much. I have to remember that my colleagues probably have questions as well, so I won't take up too many of my questions here. I'll start off, actually with the most recent topic because you, Ms. Kristen, mentioned a lot of the questions that I have my help.

So I'll start off here, Ms. Cooper, with questions regarding this continuous of care and wondering I heard the 11.5 waiver you're waiting for, the green light for funding and if I heard correctly, should be beginning in fall. But can you talk to me a little bit more about how you're looking at those three things of submitting the waiver, the guidance for counties, and the roman system modifications? Why can't that be done before the allocation of funds?

Sure. So happy to walk through some of that. As you probably are aware, in the budget act last year, this was approved to go live no sooner than January of 2025. And with the ending of the public health emergency.

As you would imagine, a lot of our time, energy and focus has been ensuring that we continue to have coverage for the 15.3 million people that are currently in our program to ensure our systems are ready, our counties are ready, and our advocates and navigators on the ground are ready to ensure people that have coverage maintain coverage. And so I think that is one thing that we have been very focused on.

We are very committed to stakeholder engagement, as we do on all of our coverage expansions, including this particular coverage expansion. We have had conversations with our colleagues in Oregon to understand their model, their process, their pieces from a state to state conversation, which is important for us to ground ourselves in that type of policy first and have something for people to respond to and react to.

When we do go out to public engagement and stakeholder engagement in the fall, though, we do imagine we will start rolling up our sleeves, even maybe late summer rolling up our sleeves with a proposal for people to respond, to, have feedback to. We usually do multiple months of engagement in regards to that. So starting even in 2023 for something going live in 25, we will start those conversations that would include our full policy pieces.

How we plan to implement it includes how we will design outreach and engagement modalities, and we have a number of stakeholder work groups that we do these design conversations with. We also did a full assessment originally on the systems that needed to happen.

One of the reasons why we all recommended, in addition to the budget potential implications, is the system migration that both Kathy and I mentioned earlier, making sure that was beyond us in regards to the go live time because this will be a pretty large system implementation, as Kathy mentioned and I did. And in my opening comments, we have to have the policy nailed down to be able to even do those system pieces, which is why we're starting to engage in those policy conversations in 2023.

We are very, very committed to that. However, we do also want to make sure that we have appropriation to move forward before we're officially going to the Federal Government with asks like waivers. Of course we will start building the waiver. We will start doing those various pieces, but we typically, until we have some either appropriation, budget or proposal in the budget, typically don't go to seek federal approval for various pieces until we have that relatively green light. Which is why I mentioned that in my comments.

Once we get that green light, hopefully in the spring of 24 from the Department of Finance, that we could proceed. We would immediately move to those actions, but again, fully committed between now and that period of time to engage with stakeholders and happy to answer any other questions. The other thing I would just add if I could, we also are working on three other 1115 waivers at this time with the Federal Government.

We are doing a lot in California and medical, and so we also have to be sensitive and aware of that with our federal partners in regards to that engagement as well I just wanted to mention that.

I appreciate, you know, doing the legwork before putting something out. I'm a firm believer that we'd work forward, not backwards setting something up. So I heard a lot of good reasons regarding number 2 and 3 on the guidance accounties and the system modifications. I guess I still, for my own learning here as a new Member, not understanding why we can't start working on getting this federal waiver ready to go for when we have the green light. We can just submit. If you could just go a little bit more on that part.

Sure. So we will do a full first we have to decide the policy. When you submit a federal waiver, there's a number of pieces we will have to have a full expense. It's called budget neutrality. Super wonky, not necessary, but we will have to work on all of those various assumptions in regards to the submission there. So we will start all of that work far in advance, and those are the types of stakeholder engagements we will start this late summer and fall.

We'll start talking through the policy design how it improves access. We will have to come up with an evaluation design that is required when we submit a waiver to the Federal Government, how are we going to evaluate increased access? We have to have hypotheses. We will engage in all of those conversations starting this summer and fall because we will have to have all of that ready for ultimately a submission.

We're hoping that there's an appropriation in the budget, as we all do, which is why we committed to it last year. And as soon as we get that, we would submit. So we would be doing all of that waiver, build, all of those policy conversations, decisions that need to be made, hypotheses on the evaluation, what we're trying to achieve, as well as our formal proposal.

That will all happen this fall in early spring, in hopes that we get that green light, we would immediately post for a 30 day public comment period, which is federally required. We would have to have two public hearings once we get that green light, it's also federally required. And then we would submit. And then CMS also does a formal federal public comment period.

So there are a lot of procedures that do have to happen, but we would do everything we can to be ready and able to post for that official public comment period in anticipation of that approval from the Department of Finance.

Would you be comfortable in saying come fall you have a little bit more tangible things that we can.

Yes, that is what we are planning for.

Perfect. My second question then I'll turn to my colleagues here is Kathy. We heard some of the issues regarding the need for workforce or just a long wait, but in your report, I didn't hear much concerns regarding workforce. However, you did mention the 44.5 million for staff time. Is that overtime? Is that new employees? And is that what you're thinking is going to address some of the concerns we heard today.

Or just our. Did I. zero, no, thank you. Sorry. zero, it's not me touching it. Okay. So it's being temperamental. What's so interesting that you asked? I had a whole little section on workforce challenges, and I thought, well, I don't know if we're really talking so much about the redeterminations here today, and so I'm going to save that and make sure they really want to hear it. Given that, I feel like I'm going kind of long. So I will address that.

We are absolutely facing the same workforce challenges that really everybody is across. I think all sectors, not just in the government counties, are continually hiring. And a lot of times when we are hiring people, we are also training our existing staff, because many in some counties, most have never done a redetermination of MediCal. I mean, we've had three years, a lot of turnover during the pandemic, and a lot of people who got hired at this point where we were doing continuous eligibility.

And so in addition to having the challenges and the constant recruitment occurring, we also know that when people are trained, they get pulled off the line. And so that could be exacerbating some of things, like the call center wait times that people are experiencing. That said, our counties are monitoring their call centers. Please remember, the call centers are not just Medi Cal. They're also CalFresh and CalWorks, in most cases to handle either initial or ongoing eligibility for those.

And so those two programs, like I mentioned in my opening remarks, are also going through their own funding and workforce challenges as well. So if anyone listening needs a job, please go apply to your nearest county. I'm not joking. I will say that we appreciate very much that DHCs has worked with counties to have them do readiness plans related to this redeterminations getting going. And the plans cover all of the types of topics that you'd hope, which is how's your call center? How's your frontline staff?

How are people coming in to just get greeted? Are there people to greet? What's your lobby management practice like so we can handle people? We're also working very hard to make sure that people are aware of the online possibilities. I know not everyone is able to do online. They may not have capacity or because of disabilities or unfamiliarity with the systems. They may not feel comfortable doing that. But for people who are able to create an account online, they can actually do their redeterminations online.

And so that is a helpful thing that we're definitely making sure as part of the messaging that we've worked very closely with GMBB, who was mentioned by one of the other speakers, the outreach consultant that DHCs hired. Part of the messaging is go check your online account, make sure your password is up to date, check your address, make sure that's up to date. And we're also trying in the messaging to be very clear. If your address hasn't changed, it's okay.

You don't have to call the county. Don't everybody call just because you hear something's happening? If you have stayed put and have not recently moved, or if you moved and you told us and you've been getting the materials, we know that you've moved.

And so really trying to nuance some of these messages so that we can have people who really need that help via phone or in person, or who really need to tell us that something has changed and haven't yet are the ones that we can dedicate those staff to knowing that we're experiencing these staffing issues. One more thing I do want to address, and that was the comment related to auto discontinuances of individuals when the counties have not yet taken action on their redeterminations.

So I assume we're probably going to get into this in more detail in a future hearing. But when a redetermination is done, as Ms. Cooper noted, the first thing we do is we try to do it on an ex parte basis, meaning we look at what we already have in the person's file. If they're on Calfresh or Cal Works, we look at that as well.

And we also go out and we match up to databases, federal databases, to see what's their income and if they're all compatible and they look eligible, we just renew them. And so in that case, the person would get a letter that says, congratulations, you've been renewed. It's based on this. They don't need to do anything. So it's those people who we cannot do that with. If we are unable to say, yes, you're eligible, then we say to them, we couldn't find you eligible.

Here is what we have, and here is what we need you to do. And so it's very targeted. It is pre filled out, a big change with the Affordable Care Act a few years ago. It's not just a big blank packet. It tells them what we need, but then they do need to send it back or call or go online. One thing that it's important to understand is all of those things are barcoded now.

And so when they are received at the county, if the barcode is scanned, it is put into the system as having been received. Even if we don't have a worker to go in and be able to process that before that redetermination date, it will be shown as received and they will not be automatically discontinued. Whether they're eligible or not, if we haven't worked it, but it shows as received. So I did just double check that real quick to make sure that I could explain that.

And so thinking about ways to manage workload in situations where a county might be a little behind, making sure that we've marked everyone that has sent their packets in as, yes, I've received these, just getting that in the system and then we'll be processing that and everything's going to get reported. There's a lot of data. Again, you're going to hear about all that I'm assuming in a future hearing. So we can track the workload.

But to the extent that if we get behind based on some of these issues people don't get harmed by, that would be our goal as well.

And so I'm hopeful that that's helpful and we'll continue to work with advocates, you all, and of course the state partners to target things like that to make sure that we're really thinking about how can we shift if we have limited staff, how do we make sure we cover the call centers, the idea of having a dedicated line, how do we look into that, things like that.

So I think we're always collecting that best practice, especially in a situation that we're facing with, we've done redeterminations, we've run this on behalf of the state since it was created, but we are in a unique situation now with this huge number of people as well as this, really just different from what any of us have ever seen, kind of labor force dynamic. So thank you.

My last follow up to that, Kathy, is we heard some suggestions regarding collaboration with CBO's. Can you talk a little bit more about that? These are the trusted messengers and communities that it worked for, the Covid-19 vaccines and awareness there. Is there any conversations regarding partnering in this area?

Oh absolutely. I know at a local level we tend to with local CBOs and organizations either kind of match up and introduce if they're having a difficult time getting in. So, for example, there was a comment where some, I think from Ms. Dar, that some of our folks are having really good luck, some of them not so much.

Well, I'd love to know what the best practices are, and I'd love to know where they've tried and haven't made those connections because we're happy to try to help with that. It really is going to take everybody working together, I think, to make sure that we get through not just the redeterminations but also successful implementation of things like the undocumented expansion that we supported. I mean, we want that to happen.

And I know, for example, in Los Angeles County, I believe they have regular meetings with a large group of their advocate partners. And so I can kind of check in with that. If there's somebody who's not included, how do they get included in our farm worker communities? I know that those counties are engaged in a lot of the local collaboratives. They've got some, I think, sort of hallmark sorts of programs where they do get in as well with their public health partners and with other organizations.

So I feel like those things are there and making sure that they're really dialed in in a situation like this, and we can try to help play that connective and supportive role.

Thank you so much. Turning over to my colleague, Senator Eggman.

Thank you. Nice to see everybody here in person. And first mean, thank you all for your work. Right. This has been a huge undertaking that everybody is engaged in. And as I hear the stakeholders talking, they point to problems and you guys are pointing to solutions.

My hope is that everybody's talking and listening to each other and making sure that we're able to address some of the issues that are going to be inherent in including a whole bunch of people in a new system during a pandemic. Right. So let's just start there. I guess my question is around, and I was concerned about the call times and the hangups and all of that, but it sounds like, Ms. Underling, you've got some continuous quality improvement going on with the offices.

Yes, that's the intent. Like I said, I know we had a very, I think, productive, in depth conversation with Director Boss related to the issue a couple of months ago and gave us an opportunity to reach out to the directors and make sure that they had the capacity in their call center structures to monitor things like the call times. And they do.

I think one of the choices that is made sometimes is how many people am I going to put on the phones and how many people I'm going to have in the office, and they try to shift around based on the demand that they think that there might be, and it can be difficult to turn on the fly.

So I think as we see what the preferences may be for people coming out of the pandemic versus coming in person versus calling and try to as well, like I said, drive as many people who are capable of self serving online to do so, but not abandon those who cannot do that or do not want to do that. Making sure that we have that door to walk in or the phone to be answered are very critical components.

And so I know that our directors take it very seriously. And so I'll be reporting back and we'll probably do some additional troubleshooting through our committees and with our board to sort of help them think through other things and if there's things that they need. I mean, certainly more staff is a huge part of this.

And we also are in some conversations right now with CalHR, which does recruitment under the merit system principles for a number of our smaller and rural counties that are seeing a particular issue right now, recruiting people, we're working with them to try to make some potential changes to those processes that might enable either a quicker process or a process where people who we know can do that job do end up getting advanced in the process. And so that's also an area that we're exploring as well.

We've got a few things going on to try to increase resources in the form of people and human capital, but also any other issues that we see. We'll certainly be working with the Department on that as well.

Okay. And how about the issue around notification that a lot of people don't know they're eligible and or don't know about the increased amount that people are able to have?

Yeah.

So the Department is actually implementing, we got $25 million in the budget last year to do a statewide media campaign that launched last month and will continue through May of 2024. Really working on how do we get statewide messaging out to make sure people understand who's eligible. The messaging around, looking for the yellow envelope. We will be doing all things in yellow envelopes so that they can kind of see that when it comes in the mail. We are trying to do training modalities.

We have everything in all threshold languages. We have created customizable flyers for clinics for anyone to use. We're working on ledge package for our Members to have available. So all really important things to really get the word out across the entire State of California. We also got 60 million for health enrollment navigators in the budget last year. We just announced those awards. We're really excited.

That's where community based organizations can really play a large role, or our county partners, of really getting that information out to trusted partners in the community across the State of California. So we're really trying to work with that, as well as many of our consumer advocates who help us get the word out as well. And they also are very good at getting us information when things aren't going right on the ground. We always appreciate hearing when something is starting to slip.

The only thing I'd other post is we will be posting all reports by county publicly during the entire redetermination. So we have an understanding engaged both for them and for us to better understand where we may need to step in and help as partners to figure out how we can mitigate things or find solutions together.

Okay. And on the issue of we've all been talking a lot recently that our seniors are our number one population falling into homelessness. Right. Something that we certainly, we want to be able to keep people housed as long as we possibly can. So can you talk about that moving to 138 level of federal poverty? Is that possible at all or is it just a budgetary issue?

Yes. So that has already gone live. So we've already extended to the 138. The other thing that we did during the public health emergency is anyone with zero income will be automatically approved. So we got a federal flexibility waiver from the Federal Government so that people experiencing homelessness will have a very easy redetermination process during this next year. And that was a huge win for us in regards to making sure people experiencing homelessness will continue to have coverage.

And then, of course, for our older adults as well. So all of those pieces are in place and will be enacted for this redetermination period.

Okay. And then on the asset test, I mean, we're going to do it one more time. We've moved it up to 130,000, and we're struggling for staff, why? Why are we going to do it one more time if everyone's going to be eligible and there's not going to be an asset test next year. Right.

So we were able to submit to the Federal Government to get a waiver between April, essentially. Actually, we'll have an effective March 1 through the end of this year so that people that essentially would be at waiving the asset through the end of this year for renewals. So people that would maybe go over the 130%, they will be able to maintain their coverage because that would become enacted January 1 of 24. We're working for the CMS to get that approved so that that would continue.

We just announced that yesterday. So it's probably why you're not tracking it, reminded me. Yes, we just announced that. We were really excited about that. We've been partnering with CMS.

I did a little dance to that.

It was brought to us by advocates to find a solution, and we were able to find one and announce that just yesterday. We're very happy about it.

Good. That's fantastic. And just as a former practicing social worker trying to, that whole asset test thing just was insane to try to get help for people. So you're saying, as we've moved from the federal poverty level up, that it's more than $600 a month that people are allowed to live on?

That particular piece is still on. That part is still, if you're talking.

About them, it was the share of cost.

Share of cost. There's different parts because there's different pieces. So we have the senior penalty for age, blinded, disabled, increased from 100% to 138% in December of 2020. There are other pieces around maintenance need and other pieces that have had previous proposals that haven't moved forward. So it just depends on which one you're referring to. And so that was something that's been considered previously but has not been approved in a budget to this point on an expansion.

But the other pieces have moved forward and have been approved as well.

I will note on the share of cost reform raising the $600, 138% was approved in last year's budget to be into effect, similar to the continuous eligibility 2025 and contingent upon appropriation. So would stress the need to continue to move toward that 2025 implementation date.

It brought it up to how much?

From $600 to 138% of the federal poverty level. So that individuals who are a dollar above the 138% have a dollar share of cost instead of over half their income. And I don't have the 138 right off the top of my head, but it's around 1300 a month for an individual.

And excuse my inartful way of trying to ask, there's a lot of numbers.

There's a lot of expansions to be honest with you.

A lot of expansions. Yeah. Okay. Thank you.

Okay. Well, just. I have one last number question, Ms. Cooper, you mentioned anticipating, I think it was a 700,000 new people in medicine. Is that the goal that we have capacity for? This is how much people have already signed up?

So it's a combination. But dominantly, those are people who, we have a little less, but around 700,000 individuals who are on restricted scope coverage right now between the age of 26 and 49 who are undocumented, that would be automatically switched over January 1, 2024 to receive full scope medical coverage. And so it does allow for a little bit of an estimate of additional individuals within the community that would also be eligible. And it is the largest expansion that we've had in a pretty long time.

And so we are really working to anticipate that we have experience with this, for example, with the ACA, when we took on a large number of people who hadn't previously had full coverage. And so we're bringing up a lot of those best practices and lessons learned as well.

So we're not calculating people who aren't even in the restrictive scope whatsoever.

No. So that 700,000 includes people who are currently in restricted.

Who haven't even signed up for Medical.

That is correct.

Actually not accounting for that. And should they also amount to 700,000, would we have that capacity to bring on 14? Okay.

Yeah, we will. We will have capacity at this point. We are preparing for all of the various coverage expansions for our network adequacy filings, which is essentially what our managed care plans have to be able to have networks for in regards to anticipating those numbers at this time.

Perfect. Thank you so much. Well, as we close out this panel, I want to thank everyone both in person and in Zoom. Some of the takeaways here is Kathy, you're going to look to see a dedicated line. I'm excited for some of the funds coming to help with the navigation and the trusted messengers. And I look forward in fall to see if we have more information regarding the continuous coverage for H zero to five and getting ready for January 2025. So we'll definitely be in touch.

More on that. So thank you. Well, some of you will remain here as we continue on to our Department of Healthcare services.

Issue two on our agenda is an overview of Department of Healthcare Services, welcoming back Ms. Cooper and then hello, Michelle Baass.

Good morning, Madam Chair, members of the subcommittee. Michelle Baass, director of the Department of Healthcare Services for issue two, going to provide a brief overview of the Department and its program and budget. The Department of Healthcare Services helps millions of Californians means access to affordable, integrated, equitable, and high-quality physical and behavioral health care, including mental, medical, dental, pharmaceutical, substance use treatment services, and long-term services and support.

The governor's budget proposes about $144,000,000,000 total funds for the department, about 39 billion general fund to support the department's programs. Of that amount, about 1.3 billion funds department operations, including about 4700 positions for the support of the department's programs. DHCS's largest program is Medi-Cal and Medi-Cal provides healthcare services for more than 15 million income-eligible Californians, including families with children, seniors, persons with disabilities, foster care youth and children, pregnant women, and other individuals.

One in three Californians are enrolled in Medi-Cal, with more than 65 of our members identifying as people of color. Medical covers 50% of all births in California, with about two-thirds of children enrolled in Medi-Cal identifying as Black and Latino, and then more than 2 and 3 patient days in California, long-term care facilities are covered by Medi-Cal. California is transforming the Medi Cal program to ensure Californians get the care they need to live healthier lives.

This includes CalAIM, our long-term commitment to offer person-centered care that goes beyond the doctor's offices, hospital and addresses their physical and mental health needs. Our comprehensive quality strategy, which includes specific metrics and goals for all delivery systems, including managed care, dental, behavioral health. As part of our quality strategy, we've launched our Bold Goals 50 by 2025 initiative, which focuses on children's preventive care, behavioral health integration, and maternity care, focusing particularly on health equity within these domains.

Our new managed care contract for 2024 creates more transparency, accountability, equity, quality, and value and really increases our expectation of our medical managed care plans. Additionally, the recent addition of benefits such as the community health workers, doulas, peer support specialists, and dietic care, and the expansions to new populations which we just covered in the first panel, want to thank the Legislature for its support and partnership over the last few years with these significant investments in the Medi-Cal program.

The department also administers programs for special populations and several other non-medical programs, including the Genetically Handicapped Persons program, the California Children's Services Program, and Newborn Hearing Screening Program for low-income for children and adults with specific genetic diseases.

Our Office of Tribal Affairs is responsible for coordinating and directing the delivery of health care to Californians in rural areas and underserved populations through the Indian Health Program, American Indian Maternal Support Services, and our Tribal Emergency Preparedness Program. Licensing and certification monitoring and complaints for driving under the influence program, narcotic treatment programs, psychiatric health facilities, mental health rehabilitation centers, and other residential behavioral health treatment providers our county mental health services and substance use disorder treatment services funded by block grants, the Mental Health Services act, our Behavioral Health Continuum Infrastructure Program, which provides grant funding to develop the continuum of behavioral health facilities and our public health prevention and treatment programs provided by the Every Woman Counts Program, Prostate Cancer Treatment Program, and the Family Planning Access and Care Treatment Program. Happy to answer any questions.

No questions on my end. Great. We'll dive in. Issue number three is on the November 2022 Medi-Cal local assistance estimate.

So just as background, our Medi-Cal estimate, we do two a year, one for the governor's budget and one for May revision, and the update at May revision will reflect updated caseload, utilization, and payment timing. To reflect the latest information we have for the current year, the governor's budget projects a $4.2 billion less general fund will be needed to support the Medi-Cal program as compared to the 2022 Budget Act.

Your agenda does a great job detailing a list of the factors contributing to this change in the budget, and I will just focus on the most significant items. In the current year, there's a 12.9% decrease in general fund expenditures compared to the budget year.

Some of this is a result in the state's projected revenue forecast, and as such we're delaying round six of our behavioral health infrastructure continuum program for about $480,000,000 and we're delaying 370,000,000 for a previously approved buyback of a long outstanding two-week hold on fee for service payments. So that's just a technical shift in where the dollars get accounted for.

And then other changes, really more related to technical changes, relate to a delay of payments of about 2.4 billion to the federal CMS related to state-only populations. 774,000,000 net reduction in costs related to COVID-19. And then in terms of the budget year, we project $138.9 billion total funds and about 38 billion general fund for the Medi-Cal program. This is a 1.1 billion total fund increase and a 6.4 billion general fund increase compared to the current year.

The factors influenced in this change is 635,000,000 to fund previously improved expansion of the full scope Medi-Cal program to eligible individuals aged 26 through 39, which we just spoke about, 307,000,000 on a one-time basis to initially fund the non-federal share of a behavioral health services kind of fund to facilitate CalAIM behavioral health payment reform.

A savings of about 317,000,000 proposed from a new managed care tax to take effect in 2024, and I know we'll be discussing that more later hearings, and about 664,000,000 related to the growth in managed care costs. Several other technical adjustments relate to 3.4 billion in repayments to CMS related to state-only populations, a $2.7 billion increase related to costs related to COVID-19, largely reflecting the assumed end of enhanced federal funding available during the pandemic, and about some other off-saving reductions of about $2.8 billion. That'll take any questions.

Does Department of Finance or LAO have any comments?

Department of Finance. No further comments.

Luke Koushmaro with the LAO. We do want to note that at the time the Administration put together the budget, there was considerable uncertainty certainty around the federal actions for COVID-19 policies, including when eligibility determinations would resume and the availability of enhanced federal funding that's been provided during the public health emergency. Shortly before the budget was released, the Federal Government announced that a few changes to the policies.

One, we now know that eligibility determinations will begin sooner than the administration anticipated, beginning one month earlier in April of 2023. We also now know that the enhanced federal funding, rather than ending immediately or at the end of the quarter that the PHE would have ended, we now will have a ramp-down process for that funding through calendar year 2023, with it declining as a percentage of the share of costs through the year until it reaches zero in January.

As a result of these changes, as well as an assessment of caseload trends based on more recent caseload data, we find that on net there will be a need for $1 billion less general fund in 2324. We are not recommending any specific actions at this time. Rather, we recommend withholding action on these adjustments until the May revision.

This will allow the administration time to reflect the changes to federal policies as well as more recent caseload data in their estimates, and then we will provide another assessment of those estimates at that time and provide our final recommendation at the May revision. Thank you.

Thank you so much. I don't have any questions. Colleagues? Senator Eggman.

Thank you. So I'm assuming after the May revise and now that we know more, you're going to come back with some updated because we had a health hearing yesterday and pretty loud and clear, people don't think that round six should be delayed. People don't think workforce funding should be delayed. So I'm sure you'll take all those things into consideration when you come back with the next updated budget.

Yes.

Okay, that's all.

Seeing no other questions, we're going to hold this item open and move on to issue number four, the November 2022 Family Health Local Assistance estimate.

Great. So for the budget year, the governor's budget estimates expenditures of 87 million total funds for the California Children's Services program, a $3 million increase compared to the current year. And just for context, the California Children's Program provides diagnostic treatment services to children under age 21 with CCS-eligible medical conditions. 136,000,000 total funds for the Genetically Handicapped Persons program, which is a $4 million increase compared to the current year, and the Genetically Handicapped Persons program is a health program for adults with specific genetic diseases.

And then finally, a 37 million total funds for the Every Woman Counts program, which is a $1 million increase compared to the current year. And the Every Woman Counts program provides free breast and cervical cancer screening and diagnostic services to California's underserved populations. The governor's budget Family Health Estimate projects 14 million less general fund is needed to support family health programs in the current year compared to the 2022 act. And with that, I'll take any questions.

Sorry, one more question here on the Child Health and Disability Prevention program transition. Last year's budget sunset the CHDP program by July 1, 2024, and preserves presumptive eligibility enrollment activities currently offered through this program, as well as other activities currently performed by CHDP county under the Childhood Lead Poisoning Prevention program.

As part of this transition, the department has convened a work group comprised of government and non-governmental stakeholders, including public health nurses, managed care plans, county social services representatives from the healthcare program for Children in Foster Care Program, and consumer advocates and others. We kicked off this stakeholder workgroup last October and have also convened in January and February and have three more meetings scheduled for March, May, and June.

The workgroup is really thinking through the elements of the transition plan as specified in the trailer bill, including children's presumptive eligibility, monitoring and oversight activities, transition and allocation of CHDP resources Childhood Lead Poisoning Prevention program activities, and establishing the healthcare program for children in foster care as a standalone program.

The department is soliciting feedback from the workgroup to develop the updated transition plan, and we plan to finalize and release the transition plan by the end of this calendar year, and we plan to include this transition plan as part of our 2024-25 governor's budget for consideration by the Legislature.

Thank you. Department of Finance or LAO, any comment?

Tyler Ulrey, Department of Finance. Nothing to add.

Luke Koushmaro with the LAO. No comments on this item, but happy to answer any questions.

Thank you. No comments questions on my end. Seeing none, we're going to hold this item open and move on to item issue number five, the post-eligibility treatment of income on trailer bill language.

Yes, happy to present on this item. The department is proposing trailer bill language to align our policies with federal guidelines. The trailer bill addresses how the department describes the cost-sharing provisions for individuals subject to post-eligibility treatment and income, the spend down of excess income required for individuals to become eligible for the Medi-Cal through the medically needy program. The trailer bill is meant to clean up our language in state statute to align with federal guidelines.

This was raised to us during the public health emergency that some of our language and terms in state statute don't align with the federal guidelines. And so we're really just aligning, there will be no impact to individuals. We're not changing any of the rules or guidelines around these pieces. It's really around the words that we're using in regards to it in state statute so that we comply.

But we do know that we will also receive feedback from stakeholders that we need to update some of our messaging on notices of actions and others to make sure it's not confusing to our members. So we'll be working with advocates over the coming months to figure out what that language looks like. How did we make sure that we're communicating what this means and to make sure that our members understand what we're telling of them?

Essentially, the department has used the term share of cost to describe this post-enrollment treatment of income rules for many years when individuals move into long-term care or have applied for what's called post-eligibility treatment of income rules correctly in accordance with the regs. And so we're really just going to be working on fine-tuning some language so people understand that they're not losing any of their access and what it means when they transition from one to another. CMS also is looking for us to do this as soon as possible, which is why we put it forward in this budget as well. And happy to answer any questions.

Thank you. Department of Finance, LAO, any comment?

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

We have not raised concerns with this proposal. Thank you.

Thank you. Any questions? Senator Eggman.

I just this again for my own education. So we're not calling sharing costs anymore. We're going to call it. How are we saying? Maggie Magi, what are we saying? Why are we saying that?

I refrain from calling it PETI, which is what it would be, because this Post Enrollment Treatment Income is not the best term, which is why, actually, advocates have come to say that's probably not the right term to put in a notice, even if it's the correct federal term. So we're updating state statute to reflect kind of federal guidelines, but we'll work on the messaging to actual members so that it is not confusing to them. But we agree, I think at the end of the day, it's not the best terminology.

Okay. I mean, everyone knows share of costs.

I think the problem is we don't want them to think there is. It's an adjustment on the income language, not necessarily the share of cost. And so it's creating confusion. When people moved into this category, they thought there was something changing, and so we have to correct that for our members so there's no confusion.

Names have changed. Protecting.

We're going to hold the item open and move on to issue number six, healthcare coverage contraceptives. Contraceptives related to SB 523.

The department is requesting three permanent positions, an expenditure authority of about $455,000 to implement SB 523 Healthcare coverage contraceptives. The requested resources will be used to lead policy development and implementation, conduct ongoing monitoring activities, and analyze covered services to determine which contraceptive services may need to be carved out for fee for service. SB 523 prohibits limitations on coverage of contraceptive coverage.

So, for example, the bill requires managed care plans to provide coverage for voluntary tubal ligation and other similar sterilization procedures, as well as for clinical services related to the provision or use of contraception, patient education, referrals, and counseling. Medi-Cal currently covers family planning, counseling, vasectomies and tubal ligations, and treatment for complications resulting from family planning procedures. However, there are certain federal requirements that apply, which may be construed as restrictions. So these resources will help us implement the bill.

Department of Finance, LAO, any questions?

Aditya Voleti, Department of Finance. Nothing further to add.

We have not raised concerns with this proposal. Thank you.

Just a quick question. I don't know if you would know this. Are plans already implementing this coverage?

So in Medi-Cal, we already cover all FDA-approved drugs or services. I think the one exception is sterilization that may not be covered under certain federal guidelines, depending on if it is voluntary on behalf and not medically necessary, in which case we will be creating a pathway in fee for service carved out of the responsibility of our managed care plans so that we can pay 100% general fund for anything that would not otherwise draw down federal funds.

And I think that's the only one exception that we identified during the bill analysis and the language that we identified, which is why we need the staff to be able to build that exception. Other than that Medi-Cal covers all FDA-approved drugs and services, as long as it's medically necessary and within federal guidelines.

Thank you. Any other questions? Great. We're going to hold that item open, move on to issue number seven, California Cancer Care Equity Act related to SB 987.

So the department is requesting three permanent positions, one limited-term equivalent position, and some contract resources to implement SB 987, the Cancer Center Equity Act. The resources are needed to develop and implement good faith effort contracting requirements for Medi-Cal managed care plans, develop and implement a cancer center referral program for enrollees with complex cancer diagnosis, develop a process in consultation with appropriate stakeholders to continually update and further define complex cancer diagnosis for purposes of referral for this program, and then conduct ongoing monitoring and oversight of our managed care plans and take corrective action when necessary.

Does Department of Finance or LAO have any comment on this?

Aditya Voleti, Department of Finance. Nothing further to add.

Jason Constantouros, LAOW we haven't raised concerns with this proposal.

Questions? We're going to hold that item open and we're going to move on to item number eight, maternal pandemic-related mental health conditions as it relates to SB 127.

The department is requesting two permanent positions, an expenditure authority of $310,000 in the budget year, and ongoing. The positions are needed to implement the requirements for managed care plans to develop a maternal mental health program that is aligned with our comprehensive quality strategy and goals to drive improvements in maternal and child health outcomes. Managed care plans must develop the maternal mental health program by July of 2023.

The requested resources are needed to lead policy development and implementation design provide technical assistance to managed care plans over the course of implementing these various measures, as well as developing monitoring tools and protocols. Resources will also be used to work with the Department of Managed Health to ensure that we are aligning in regards to implementations here. We also will be monitoring the compliance, various quality metrics that would be needed, education, training, and member education that would come into the future as well. And so happy to answer any questions.

Does LAO or Department of Finance have any comments?

Aditya Voleti, Department of Finance. Nothing further to add.

We haven't raised concerns with this proposal.

Perfect. Thank you. Colleagues, any questions? We're going to hold the item open, and we're going to move on to issue nine, the Whole Child Model, the trailer bill language.

The Department of Healthcare Services is proposing to implement the California Children's Services, or what's known as CCS Whole Child Model, in 15 counties converting to the county-organized health systems, or COHS, and single plan models as a part of the county model changes that are going live January 1 of 2024. It will be a phased implementation, which I'll get to in a second.

We're also proposing to mandatorily enroll foster children in single-planned counties to align with that, sorry, mandatory, enroll them into managed care plans to align with the policy in COHS counties across the entire State of California. There are approximately 173,000 children in CCS, with a little under 31,000 or 18% in the Whole Child Model today. This would bring the total of Whole Child Model counties to 36 and around 47,000 children, or 27% of the children that are CCS eligible, into the Whole Child Model.

With existing Whole Child Model managed care plans scheduled to expand to new counties in 2024, we are hoping to align the policy for those managed care plans. For example, partnership will be adding a large number of counties to them as a COHS plan, and we do think it's important that our managed care plans are treating all of their various counties and members consistently, and CCS is carved into the managed care plan's responsibility in those counties.

And so that is why we are moving forward to standardize this. Where managed care plans have expanded and where counties have chosen, through ordinance being passed to move into these COHS models. Across the State of California, there was every county that elected to move into these COHS models went through a public hearing process. They had to pass local ordinances to move into COHS models in the State of California.

For our codes, including the partnership model, CCS is carved in under the Whole Child Model in those particular counties. So that is why we're moving forward with our recommendation regarding that. It will be a phased approach, though, because we have consulted with the counties in 2022 to understand what this would look like. The first phase will be focused on dependent counties. A dependent county is someone where the State of California actually does the authorization for CC services or the coordination ourselves.

Those would transition first, and the second phase would be independent counties, and that is where the county themselves do those CCS coordination pieces and eligibility pieces. So phase one is being proposed in 10 Cos expansion counties that have a dependent county designation in the CCS program by 2024. And those 10 counties include the various counties in partnership health plans. So Colusa, Glenn, Nevada, Plumas, Sierra, Sutter, Tehama, and Yuba, and then in our alliance counties in Mariposa and San Benito.

Phase two would implement Whole Child Model expansion in two COHS expansion counties that have independent county designation in the CCS program, as well as the three new single plan counties by Jan 1 of 2025. So a two-phased approach here with our partners and that was based on feedback we received from our county partners in regards to how to transition this and allow for capacity policy building and transition regarding the whole child model independent evaluation the Department of Healthcare Services is aiming to release the independent evaluation of the whole child model by the end of March. Due to delays on ADA and DE identification, we have not gotten that report out publicly.

However, we have gone and made sure we are educating people about the outcomes of the evaluation. We actually just did a leg briefing for leg staff yesterday on the full evaluation outcomes. We also have briefed our CCS Advisory Committee. We have briefed managed care plans, CHIac, and many of our various advocates, and we will continue to educate people on the evaluation outcomes. The department contracted with the University of California San Francisco Institute for Health Policy Studies to conduct this independent evaluation.

The evaluation is organized by research questions that addresses each evaluation question that was identified in the original SB 586, which was negotiated between the administration and the Legislature at that time. The department's decision to proceed with proposing the implementation of Whole Child Model in these counties where it's expanded, really was supported by the results and conclusions identified in the independent evaluation by UCSF.

The evaluation report identified that the Whole Child Model had similar or same results as the classic CCS or an improved impact to the majority of the CCS client participants across the majority of evaluation measures as compared to the classic CCS program. The evaluation concluded that the CCS Whole Child Model maintained services and provided CCS level quality of care for the majority of CCS clients in the Whole Child Model. It increased access to CCS paneled providers, had lower grievances, streamlined DME referrals.

Satisfaction was either unchanged or improved for the majority of members as reported by the independent evaluator. Quality was maintained, including in HEDIS measures where most of them were improved or stayed the same, inconsistent with classic CCS. And so there were some. Also some areas of improvement which we noted in regards to the evaluation, which we will take very seriously to look at, one of which is CCS enrollment, where on average the absolute difference between the Whole Child Model and classic CCS counties for new referrals was about a one to 2% difference.

I know that's a small percent, but one of the core factors that we wanted with whole child models to have no disruption of an individual who is CCS eligible from being designated as CCS because as agreed to in SB 586, there were certain protections that come along with being a CCS individual. And so we will work with our managed care plans to ensure that there are processes in place to make sure they are identifying CCS children and referring them to be formally enrolled in the CCS program so they could have those additional protections, including a provider bump that is correlated to that. We would also note that the evaluation period was during the public health emergency, so we also saw it as promising that the evaluation also still showed pretty high improvement and or consistent with the classic CCS.

And we did see the variation in regards to that again, for the majority of the measures, not all. And we mentioned some of the areas where we're wanting to see some continued improvement. They also noted that care coordination needed some improvement for both the classic CCS and the Whole Child Model. So we'll continue to work with our CCS partners in the county as well as our managed care plans to really improve the care coordination for these individuals when it comes to CCS reimbursement.

When a county transitions from fever service to the Whole Child Model, existing law requires that medical managed care plans pay physicians and surgeons a provider bump. So there was negotiated in SB 586 that anyone who transitioned over has to maintain that physician bump in regards to these services, and that is required for these individuals as well. When it comes to the hospital quality assurance fee, as we have heard, some of our children's hospitals are anxious around this transition.

We have had conversations with them in those payment programs. The methodology to determine the amount of supplemental payments to hospitals and fee for service delivery system includes factors to account for high acuity stays or services. However, under managed care, the directed payment programs that we use, it is the same per diem or add-on regardless of that acuity, and so they have some questions about what this transition means for them.

The department is committing to working with our hospital partners to modify the structure of the managed care-directed payments and to have those conversations to account for the differences more appropriately for future programs. The next iteration of the hospital quality fee that we'd be submitting would be for calendar year 2025.

However, I would note that under the fee-for-service program, the payments are based on historical utilization, which means the impacts of the trailer built on utilization for our hospital partners would not be realized until at least calendar year 2026. So we have time to find those solutions for our hospital partners as we continue to have conversations with them.

And in fact, in calendar year 2024 for counties where Whole Child Models expanded, hospitals would receive supplemental payments under the fee for service program based on calendar year 2021 utilization when ccs remained in fee-for-service, and they would also receive supplemental payments under the managed care directed payment program for calendar year 2024 utilization when the member was in Whole Child Model.

So essentially an enhanced payment for a two-year period of time for those hospitals as we transition and find solutions moving forward. The department is very committed to working with all advocates or individuals who are concerned around this expansion of whole child model to hopefully find a pathway forward where we can continue to standardize services in those COHS counties where Whole Child Model is already carved in today.

Does Department of Finance or LAO have any questions? Comments?

Aditya Volet, Department of Finance. No further comments.

Jason Constantouros, LAO. Before diving into our comments, just thought it might be helpful just to point out some parts of your agenda that might be helpful to follow. On page 30, you will see a list of the existing counties that participate in Whole Child Model. That's where it says participating counties and then participating health plans are the health plans that operate in those Whole Child Model in those counties.

Turning to page 31, you can see a list of all of the managed care model changes, and all the way up to Yuba, you can see the list of counties that are transitioning to single plan or the COHS model, which are the counties sort of impacted by this proposal. And then moving towards the bottom of page 31, you can see the two phases there and the counties affected by each phase. Now, we think this proposal raises a few key policy considerations for the Legislature.

First, we understand the department's rationale of wanting to align with the managed care model changes and also to further standardize the way services are delivered across the state. And we think that rationale warrants consideration. We also note that stakeholders over the years have raised concerns about the potential impact of Whole Child Model on access and quality of CCS services, and we understand the evaluation was intended to shed light on a lot of those concerns.

As the administration noted, it did brief legislative staff, including our office, on some of the key conclusions of that evaluation and anticipates releasing the full evaluation later this month. We recommend withholding action until that full evaluation is released later this month. When that evaluation is released, we're happy to work with the committee further on parsing through that evaluation. We think there are a couple of key issues. The Legislature want to keep an eye out in that evaluation.

One, of course, is the differences in access and quality of services and Whole Child Model compared to traditional CCS. The administration walked through some of those key differences already. We also think it'll be important to notice where those differences were largest and how notable those differences were.

Some of that information is still sort of forthcoming in the evaluation. And then finally, in which counties those differences were most notable and what that might suggest about the impacts of expanding Whole Child Model to the proposed counties in this proposal. We also think the Legislature will want to continue to work with the administration to understand the financing implications of this proposal and ensure it's comfortable with those implications. Depending on these factors, the Legislature has options here.

If it's satisfied with the various trade-offs with the proposal, it could approve all or parts of the proposal. Or to the extent that it needs more time to deliberate on these issues, it also could defer some of these decisions and discuss them and contemplate them further. So, again, happy to be available for questions.

Great. Thank you. And Ms. Cooper, I really appreciate you giving some highlights to this, but I'm on board with that. I really want to read this report and make a decision on that because I am a little hesitant that the evaluation took a little time to come out, and I don't want to jump here before getting things that are evidence-based that are actually going to work for every single county. I'd be hesitant in passing something that leaves out just even one county because that could be detrimental to a lot of patients. No questions. That was just a comment. I'll turn to my colleagues. Senator Roth here.

Thank you, Madam Chair. You know, I'm probably a little out of date. My recollection of managed care is it works best when it balances acuity. It works best for providers when the acuity is balanced right and here am I wrong?

That's a big question.

Well, we're talking about capitated payments, in essence, aren't we?

Right. But there are different rates paid by different acuity levels.

You get paid per life.

But adjusted by acuity as well.

Adjusted, but it's sort of a global thing when you sign up to this. Here, we're talking about kids, basically, and some young, some not quite so young, with very high acuities in a medical field in the State of California, where many hospitals don't even have pediatric beds, certainly where I come from, they don't have pediatric specialists. Those tend to be located in very specific facilities. And yet we're taking a process that has seemed to work fairly well, fee for service, and we're changing that.

And so I guess I have a couple of questions. The first one is, why are we doing this? Are we doing this to save money?

So, no, I just want to remind everyone, we already have around 31,000 children in the whole Child Model Program today across 15 counties in California. And so we are evaluating that initial transition that took place between 2018 over multiple months in multiple counties across the state.

We haven't seen the evaluation.

We will be releasing the evaluation.

I'm concerned about the differences in treatment, the differences in outcome, and you tell me that UCSF has done a study and there are no significant differences. Well, I'd like to see that because we're talking about putting people in a managed care situation that may or may not provide care at dedicated, highly specialized children's hospitals. Guess they have to sign up to the program, don't they?

There's a number of protections that were negotiated with the Legislature originally around SB 586 to put many of those protections. For example, even enrolled in managed care, all CCS kids still need to see CCS panel providers, or they are required to also coordinate any out-of-network care. What we also saw is that most managed care plans significantly increased their network to have better access for these various CCS paneled providers.

I don't have the stat in front of me, but I believe the independent evaluator said close to 90% were all seeing CCS paneled providers in their networks, and most were expanded their provider networks significantly to meet the needs and coordinate those services. Evaluation looks at those types of things and then points out any differences by managed care plan So you can see the differences across those various areas.

I guess back to my original question, why are we doing this? I realize you have it working in other counties. That didn't address the question, why are we doing it? What was the goal? And the objective in doing this in the first place, and I was here and I was probably on one of these committees, but I just don't remember.

I'm happy to walk through that. So the reason why we are recommending to add is tied to the managed care procurement that we have a large piece going live January 2024, we allowed all counties to decide if they wanted to change their model of managed care in their county. And so starting in 2020, we were working with counties across the State of California to say, if you want to move, we have different models of managed care in California. Some counties only have one managed care plan.

Some counties have two managed care plans, and some counties have multiple managed care plans for MediCal. But counties had come to us saying, we want to change our model of care, and we want you to consider that before you decide who your commercial plans are going to be across the State of California. And we thought that was reasonable.

So we gave counties an opportunity to go to their boards of supervisors and essentially pass an ordinance if they wanted to change their managed care model for MediCal. And we had a significant number of our counties change their model, many of which changed from what's called a two-plan model to a single plan. And we call those COS in California, county-organized health systems. And that's where essentially, you have one managed care plan for that county. And partnership is a good example.

Partnership is a whole child model county where their existing counties have CCS carved in. And so when those counties made that change to go to a COS, they made that to choose going into the Partnership Model of Care and into the County-Organized Health System Model of Care. And in this example, we had carved CCS in. And so we are recommending to align that policy for all of the future counties that will now be in Partnership Health Plan.

So Partnership Health Plan then, is treating all of the children in their managed care plan consistently across all of their counties. Otherwise, they will have to essentially treat some of their counties with CCS being carved in where they're responsible for doing these various pieces. And some, it would be carved out to the county to continue to provide services only for the CCS services. I mean, that's one of the complexities around CCS.

It's not that the county does all of it, or all of the children's services are in fee-for-service. Those individuals are actually enrolled in managed care today. It's just their CCS condition that is carved out to fee-for-service. And this has created really complicating factors around coordination and pieces historically.

Which is why Whole Child Model and SB 586 moved forward to test and evaluate whether we could see that access and quality and managed care for children with complex medical conditions, because I think we all agreed we wanted to make sure that that was successful before moving forward with any expansions. It's really the 24 change of model changes that's driving this expansion at this time.

Well, other than the complexity in managing it at the county level, but lots of things are complex. What's the incentive for a county to select the managed care model for the CCS services?

So the counties selected through ordinance to move into a COS Model or the Single Plan Model. And that was done because they wanted to pick their managed care plan partner. And in those counties, they chose Partnership, that they would prefer Partnership to be their partner versus having a commercial plan and maybe another plan. And we let the local people drive that recommendation, so they chose kind of their managed care model. This particular change is really around within that model.

In California, we have CCS carved in as a responsibility of that managed care plan. And so I think that's what we're now proposing is to align that policy for those counties as well. And I think those are the conversations that we'll have to have with those individuals. We do come to it with experience now, having gone live in the other counties, but that is essentially what we're proposing.

And I don't know if you want to add anything.

No, I just wanted. You already said it. But really, the goal with kind of putting it together is that you have one plan that coordinates all services for the child. It's not the CCS pieces carved out, handled by the county CCS program. It's all coordinated under one managed care plan.

For example, one of the things that we're seeing increase is that children are getting higher referrals to behavioral health services now that they're enrolled in managed care, because the managed care plan is responsible for coordinating all of their services, not just the CCS. That's carved out for just the CCS condition. So say you have someone with a complex medical condition carved out to the county.

They're only responsible for the care coordination of that particular diagnosis and system, but the managed care plan, when they're able to look at all of it, they can make sure they're getting that critical care, which is very important, but making sure they're also getting those referrals to behavioral health. And we've seen that improve when they're responsible for coordinating all of the services for the kids instead of it being a kind of siloed and divided responsibility at this time.

Well, this will certainly be something I'm going to be watching very closely because obviously, behavioral health is very, very important, but the conditions that cause young people to be in the CCS Program are very serious. And so the question is, is the managed health care plan under this program going to be able to get the appropriate level of care and deliver the appropriate level of service to those individuals who are in the CCS Program for the CCS condition?

And I guess some managed health plans probably managed care plans probably do well with behavioral health, but we also know there are some who are not doing quite so well with behavioral health for a whole variety of reasons, including workforce. So sometimes that works and sometimes that doesn't. So I look forward to taking a look at the evaluation report, and I'm sure we'll be talking about this more. Thank you very much for what you do, though. Thank you, Madam Chair.

Senator Eggman.

Thank you. I'll also be very interested in reading the report, because during the briefing, it sounds like it hasn't been a flawless plan. And then to expand it makes people a little bit anxious. Can you talk a little bit about, are there participants in CCC for a diagnosis that also have private insurance, commercial insurance, and how are we bringing all of that in to offset some of the MediCal burden?

Yeah. So CCS is one of those programs where we have CCS MediCal, and individuals on MediCal can also have other health coverage, Medicaid and MediCal in California is always a payer of last resort. And so our managed care plans and us, as the Department of Healthcare Services, are used to coordination of benefits in that regard. We have a lot of experience with that.

We also, in California have what we call CCS State-Only where a higher threshold for income, someone can become eligible for CCS, but we pay 100% state General Fund for those services. So we have experience with both. And it's usually sometimes in the higher, where the coordination of care is needed. But oftentimes, if they need that additional coverage and they're eligible within the income, then we just work on that coordination of benefits with their private insurance.

Like for referrals to behavioral health or something. If somebody had a private, which is not their diagnosis that they were in CCS for, then they could be out of the system.

Yeah. So it could be something where we cover something that their insurance doesn't cover, for example, or they have to maximize their private insurance before we would pay. And we do that on a regular basis. Yes.

Thank you.

Thank you. We're going to hold that item open and move on to the last item in this Department. That's proposals for investment. Thank you. I'd like to welcome the presenter of this proposal. It's going to be Lucy. I'm not even going to try. I'm so sorry. Yes. On behalf of Maternal Child Health Access.

Lucy Q works fine. Good afternoon, Madam Chair and Members. Lucy Quatchinella on behalf of Maternal and Child Health Access, which is a community-based organization in Los Angeles serving literally thousands of families, individuals every month and also engage in statewide policy work. We appreciate this opportunity to address such an important issue. Low-income people in California during pregnancy who have MediCal bear a disproportionate burden of social factors that can harm their health.

And that is according to data from the California Department of Public Health. Even before the COVID-19 pandemic, Hispanic and African Americans with medical during pregnancy were significantly more likely to experience harmful social conditions. And the pandemic has only made those conditions worse. Examples from the Department of Public Health survey include significantly greater rates of food insecurity during pregnancy, homelessness or no regular place to sleep, having to move due to problems paying rent or their mortgage, job loss, and this last one, I think is really profound, no practical or emotional support.

These conditions don't just disappear at the end of the initial 60-day postpartum period. The proposal that's requested is to align MediCal's Comprehensive Perinatal Services Program benefit, which currently ends at 60 days postpartum, with MediCal's new 12-month post-pregnancy eligibility, and that took effect in April of 2022. The first year is critical not only for mothers and newborns, but also for people who experience miscarriage or stillbirth.

A key component of MediCal's CPSP benefit is integrating non-clinical supports with medical care based on assessments in each trimester, and postpartum. Services like support groups, peer counseling, help or referrals with transportation, food, housing, immigration status concerns.

These things help families avoid, mitigate, or resolve harmful social conditions before they develop or make the person's health worse, requiring interventions like those available under CalAim. Research shows that tracking prediagnosis, stress or anxiety early with low-level interventions can help prevent more serious maternal depression and even suicide, which tragically is a leading cause of maternal deaths in the later postpartum period, well beyond the first 60 days.

CPSP also requires warm handoffs to higher levels of care, such as to psychiatrists when that is needed. Breastfeeding support is often essential well beyond the first 60 days, and CPSP is the main way that providers can Bill for these essential services for families. CPSP also requires that families be given information about newborn developmental screens, immunizations, and other health issues, as well as offered assistance with scheduling pediatric visits and transportation if that is needed.

So CPSP for 12 months postpartum could be part of an effective strategy for combating MediCal's very low rates of pediatric preventive care. They're somewhere around 25%. Comprehensive perinatal health workers are part of the CPSP care team. They provide nonclinical supportive services as part of the team so that doctors, nurses, and other medical providers can work at the top of their licenses while their patients get help with social needs from the integrated care team.

The state's rules, in our view, need to be updated so that these comprehensive perinatal health workers can be most effective by assisting people in their homes and elsewhere in the community, not just at a medical facility. The budget request would also include this change. California has done some amazingly wonderful improvements and expansions and reforms in MediCal in recent years, which my client, Maternal and Child Health Access, has very vocally supported. One of these is the Community Health Worker Benefit, the Doula Benefit, and others.

Those may overlap in some ways with CPSP, but they do not make CPSP irrelevant. They do not completely take the place of CPSP. They may result in the need for less utilization in CPSP, and that would be fine if people's needs are being met elsewhere. But there are things that CPSP does with an integrated health team utilizing experienced, trained, comprehensive perinatal health workers that none of these other reforms that we support would replace.

Best practice models in California exist throughout the state that use the CPSP approach. For example, here in Sacramento, Black Mothers United was founded over a decade ago by a person who is both a doula and a former CPSP worker because she felt the need to deliver these services in the community in an integrated way. The Respect Initiative in San Francisco also relies on CPSP, Beloved Black Centering in Alameda, West County Clinics in rural Sonoma County, and there are many other examples.

Programs like these could extend their reach and services during pregnancy and the first year after if the budget request were approved. I'd just like to make one final point. In MediCal I think the Department indicated earlier that approximately 50% of California's births are covered by MediCal. I think maybe now that number is a little lower. According to the Department of Public Health, it may be more like 43% based on recent data, and yet in many counties, it's significantly higher.

For example, in San Joaquin, 55% of births are covered by MediCal. In Kern, 69%. In Kings, 58% of births are covered by MediCal. Tulare, 70%. Madera, 74%. Riverside, nearly 49%. And Los Angeles County, with its large, large population, 45.5%. So making more of these prediagnosis preventive services available to families in the first year after pregnancy ends would contribute significantly to available resources. So we don't have to go to the higher levels of care.

So that when a doula isn't available, when the workforce for the community health worker isn't available, when the expertise, the training that the comprehensive perinatal health workers isn't otherwise available in a practice, we have CPSP to rely on. Thank you very much and happy to answer any questions.

Thank you so much, Lucy Q. Does the Department of Finance or LAO have any comment?

Kendra Tully, Department of Finance. No comments at this time.

Great. Quick question. I think clarification I need. In the beginning, you mentioned this program could sit in a current program within the Department. Is that correct?

I should have been more clear, Madam Chair, the Comprehensive Perinatal Services Program, it's a little confusing. It's called the Comprehensive Perinatal Services Program, but it's actually in our state statute and part of our state MediCal plan approved by the Federal Government as a MediCal benefit. So, for example, our state MediCal plan has physician services as a covered benefit. We have prescription drugs as a covered benefit. We have chiropractor services as a covered benefit. We have mental health on and on and on.

CPSP exists at the same statutory level and at the same level in our state plan. So it's as if we're saying in California, having failed to extend this particular benefit for the full 12 months after pregnancy and shutting it off at 60 days, it's as if we're saying, well, we're going to stop the physician services or we're going to stop prescription medications.

We should have the full range of what California and the Legislature have decided is necessary to support families in a preventive space available throughout that year. There is a real need for this. Again, I go back to the lack of just practical and emotional support. You don't need a psychiatrist to deal with that.

And the OB and the general practitioner is probably not the best person to be working with a family to make sure that glue happens, that the family that needs these kinds of social supports gets to the right place, and has the appropriate level of coordination for those nonclinical supports. And yet, at the same time, the medical care team needs to be aware of what's going on.

Thank you. You have three senators here that are really passionate about behavioral health, two of which are social workers up here. And two weeks ago, I got a briefing on just this. The maternal death and how it's rising in the State of California. And Latinas make about 48% of people giving birth in this state, and their rates for maternal death has increased.

And you pointed out something that I think it should sit with us, that most of our maternal deaths happen post 60 days, and it's very preventable. I don't have to repeat what you said, but I'd like to first turn to the Department to just any kind of response in this area just curveball at you. I'm not sure if you knew this question was coming your way, but.

Appreciate Lucy's passion on this topic. We've been in discussions on this for about a year or so, and also just want to recognize as part of our bold goals, by 2025, maternity care and kind of improving maternal outcomes is one of our clinical focus areas. We see the data. We know that this is something we need to address, and a lot of our initiatives are aligned to addressing this particular issue, and we know we want to do better here.

Colleagues? Senator Eggman.

And just thank you for the clarification, because when you were first talking about it, I thought, well, how is that different from the doula services that we've talked about recently? So how are we going to, in your mind, make sure that there's not a lot of overlap as we're all talking about our workforce crisis and not having enough people? How are we going to make sure there's not three people treating one person?

I think that's a great question, and it's something we've given a lot of thought to. We know the Department is expert on many things, and ensuring that there's no duplicate payment is one of the things that they're really good at. So this is not the only place in medicine where there's the potential for overlapping service. So, of course, we would want to work with the Department, and they have the expertise to set up the right systems to control that.

The other thing that I would really like to emphasize, though, is that on the workforce issue, this is what's so motivating to us. This benefit in the MediCal program and in our federally approved state plan has existed literally for decades. And so we have, in California, developed a workforce. These comprehensive perinatal health workers who are part of these teams. Now the requirements to be a CPHW, a comprehensive perinatal health worker, are actually more stringent than the requirements that have been adopted for community health workers.

We have no problem with that. We think the standards for chws community health workers are excellent. We work with the Department and the stakeholder groups to develop those. We think they're fine.

But I want to underscore that we have this very experienced and expert work team of people who speak Mixteco, who speak the non-Spanish indigenous languages, who are also, in many cases, promotoras, who work in the African American community, and who are accustomed to working with the general practitioner, the family doctor, the OB, as part of the clinical care team. Why are we not taking advantage of that resource? Why aren't we leveraging it while we build up the doula workforce, while we build up the CHWs?

And the other point that I would emphasize is that not every practice is going to focus their community health worker services in the perinatal space. And so we have this ready-made MediCal benefit that complements completely the public health or the population health management strategies that I think the Director has been referring to. A quality assurance strategy on public health or population management. I'm sorry, old habits die hard. Population management, that's a quality assurance strategy.

The Comprehensive Perinatal Services Program Benefit can work well with that strategy, just like the Physician Benefit is going to have to work well with population health management, just like dental, et cetera, et cetera. So we'd really like to be able, we feel that these maternal deaths are in many cases preventable tragedies. And sometimes the lower-level interventions can make a significant contribution in the community resource, in the village to prevent things from getting worse.

We need to throw everything we've got at this problem. On the way in today, I was listening to the latest report at the national level. The U.S. is even worse now than it was in previous national reports on maternal deaths. It's something like 32 per thousand, compared to only two per thousand in other economically developed nations. So this is an opportunity to work with people at the first signs, to take advantage of the support group structure.

Again, you don't need the psychiatrist, you maybe don't even need the licensed clinical social worker, but it's profound, the impact that having those community supports can bring.

So you're suggesting there's a massive workforce out there just waiting for us to pass this and then it'll be all funded?

Let me just clarify. I don't mean that there's a massive workforce out there of comprehensive perinatal services workers. But you bet you, Senator, in these programs, because it's a MediCal benefit during pregnancy in 60 days. Right? And these people. My phone is ringing off the hook. It's like, why can't we continue doing this and know that there's compensation after that initial 60 days? We have built a relationship with this person who has been substance-involved, for example, during the pregnancy.

And now she's stable, and she trusts us, and we want to keep her stable. And this support group that she's coming to every week is working for her. So we don't want to shut that off over 60 days. And we really don't have the funding resources to continue it beyond 60 days. It's a situation that we can deal with if we make more resources at that level of care available in the community with this level of practitioners who work then with the licensed folks.

Okay. Director Bass or Ms. Cooper. I worked on some legislation, and then it kind of happened through the budget, like, two years ago to expand MediCal postpartum for a year. Correct? So that's already done. That's done. Okay. And I guess I just wanted to say as we're also facing a crisis with our hospitals and trying to keep them afloat, and when we think about a MediCal birth, it's approximately $18,000.

So for us to try to stop the bleed on our hospitals, it makes all the kinds of sense to me in the world to be able to make sure people stay healthy and don't have to have return trips back as we face a reduction in acute care services. Thank you.

One last question to Department. Say we get the 2.4 million from the state. Is that something that, close to what Senator Eggman asked is, we have the money and that's it. The program is ready to go as you'd be able to just expand it or would more be necessary?

As was mentioned, all of the services covered in the program are also separately available for MediCal individuals to receive in the postpartum expansion that was mentioned. So I think we would have to look at the duplication processes. And also, as Michelle mentioned, we are working on a comprehensive quality strategy, specifically on maternal outcomes as well as the disparities in maternal outcomes. And we are launching a very large workgroup in regards to what are the best clinical care guidelines for maternity.

How are we going to target where we're seeing disparities today in the maternal outcomes to do more targeted interventions? Because what we are doing in our program today is not closing those gaps. And we are looking across the new Doula Benefit community health worker and all of the dyadic services that were just added in partnership with the Legislature. We have all of these moving pieces. We have all the benefits you need.

If you look at out there, California, on paper, we have everything you need to have great maternal outcomes, but we need to make sure that we're bringing it all together. And I think that's where we really partner in regards to working on those things. So if this were to be funded, we would have to partner to figure out what that looks like. What is that model of care? What are the various pieces we're pulling together? But it has to all be improving health outcomes.

In all the various pieces that we've had in California, we're still not moving the mark on actual quality outcomes for individuals. And that's what we're trying to get to the core at the Department of Healthcare Services today. And we are launching this year a very large stakeholder process, what we're calling our Birth Equity Pathway, to really focus on that particular work with our advocates and our partners.

I think just to underscore how it's important to coordinate all of this. And so there's not all these independent delivery systems or programs that aren't all pulled together. And I think that's what we're really trying to do is to comprehensively look what's out there and how do we pull it together so that not only from the member's perspective, but from outcomes perspective, follow-up visits happen, whatever it may be, is coordinated.

Great. Thank you so much. Thank you for presenting that proposal. I do want to know, under this issue, issue 10 proposals for investment, the Subcommittee did receive three proposals for investment in the Department. We only heard from one, but I just want to publicly say that the other two were the MediCal Health Enrollment Navigators Project budget augmentation asking for 60 million to support the MediCal Health Enrollment Navigators.

And the second one was for the housing preservation for long-term care residents, asking 44 million annually to support increasing the home upkeep allowance,, HUA from 209 per month to actual housing costs of up to 138% of the federal poverty level. Just to note. Thank you so much for your participation. So we're going to leave those items open and move on to the next department, the Emergency Medical Services Authority.

I'd like to welcome the Administration joining us in person and online. We're going to start off with issue number one, which is an overview of EMSA.

Hi, good afternoon. My name is Richard Trussell. I'm the Chief of Administration at the Emergency Medical Services Authority, which I will refer to as EMSA. As requested, I provide a brief overview of the Department and our current EMSA proposals under consideration.

EMSA was formally established by the EMS System Act in 1980 as the state lead agency and centralized resource to oversee emergency and disaster medical services in the State of California.

EMSA is charged with providing leadership in the innovation and the Administration of the Emergency Medical Services, or EMS system throughout the state, which includes setting standards for the training and scope of practice for various levels of EMS personnel.

We're also responsible for promoting disaster medical preparedness throughout the state and, when required, coordinating and supporting the State of California's medical response to major disasters. EMSA works closely with many local, state, federal agencies, private enterprises, and those in disaster medical service roles to promote quality EMS services statewide.

The EMS Authority's program functions are organized into three separate divisions, the EMS Personnel Division, the EMS Systems Planning and Development Division and Disaster Medical Services.

The EMS Personnel Division develops and implements regulations that set standards for training, certification, licensing, and scope of practice for emergency medical personnel, including EMTs, advanced EMTs, paramedics, mobile intensive care nurses, firefighters, peace officers, and lifeguards. The EMS Personnel Division licenses and disciplines paramedics statewide for civil and criminal violations of the California Health and Safety Code.

They also approve first aid and CPS training programs that are required for childcare providers and school bus drivers. The EMS systems division coordinates local EMS systems, statewide trauma system, and the California Poison Control system.

This division establishes regulations and guidelines for local EMS agencies and review and approve local EMS plans to ensure that they meet the minimum standards. This division also manages the state's data collection, EMS data collection, quality assurance, dispatch and communication standards, and EMS for Children efforts.

The last division, or the third is the Disaster Medical Services Division, who fulfills EMS' role as a lead agency responsible for coordinating California's medical response to disasters.

The division organizes the statewide network to provide medical resources to local governments in support of their disaster response. This may include the identification, acquisition, and deployment of medical supplies and emergency response personnel from unaffected regions of the state to meet the needs of disaster victims.

Response activities may also include arranging for the evacuation of injured victims to hospitals in areas regions not impacted by the disaster, and the Disaster Medical Response Division maintains, staffs and deploys the state's mobile medical assets program. That's the end of the overview. I kept it brief.

Thank you. I appreciate that.

You're welcome.

Any comments? All right, we're going to dive into it. Issue number two, EMS personnel human trafficking training implementation as relates to AB 2130.

EMS is requesting $84,000 in General Fund in 2324-2425 and 25-26 to recruit and hire temporary staff to coordinate and support the implementation of AB 2130 which requires emergency medical technicians, advanced emergency medical technicians, and paramedics, upon initial licensure to complete at least 20 minutes of training on issues related to human trafficking.

The United States Department of Homeland Security identifies EMS providers as one of the service providers most likely to encounter human trafficking victims.

In 2020, California had both the largest EMS provider population in the US and the highest number of reported human trafficking incidents, at nearly 10% of all reported incidents nationwide. Sufficient coordination and support is essential to meet EMSA's responsibilities to train personnel throughout California who can recognize and report potential human trafficking incidents.

Although many training programs include human trafficking in their curriculum, AB 2130 requires EMSA and the LEMSAs to determine that all initial training programs providing training related to these issues with human trafficking.

To meet these requirements, EMSA will require regulatory updates to incorporate the new standard for all program types and configuration updates to our central registry. Approval of this proposal will support EMSA's ability to provide leadership, revise training standard requirements, and enhance the central registry licensing and certification system by establishing workgroups and coordinating outreach and education to the LEMSAs. EMSA will train central registry licensing and certification users.

In the successful review and approval of this new initial application training requirement. EMSA will use existing position authority to establish the staff support.

Does the Department of Finance or LAO have any comment? Great.

Will Owens, LAO no concerns with this proposal.

I worked as an EMT for five years, so I'm very excited to have future EMTs be part and receive this training, because you are right. We go to the nooks and crannies of cities and counties, areas that sometimes are in the dark for the rest of the people, and we're exposed to a lot of things. So I'm excited for the potential implementation of this excellent. Nothing great.

We're going to hold that item open and move on to issue number three, diversity, equity and inclusion strategic plan development.

EMSA is requesting 100,000 General Fund in 23-24 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 to reduce health inequities and disparities and to support EMSA's emergency medical service system strategic priorities. Health equity has been a key focus of the Administration, and the Covid-19 pandemic accelerated the need for additional action.

It's critical that Californians of all ages, abilities, and backgrounds have equitable access to the conditions that optimize health. This is especially critical for communities that have experienced socioeconomic disadvantage, historical injustice, and other avoidable systemic inequities.

To do this, EMSA must coordinate with CalHHS so that its policies and programs are strategically aligned to further statewide equity goals. Health equity, workforce diversity, and inclusion are critical elements of the CalHHS mission to identify and address long standing barriers to the health and wellness of diverse populations throughout California.

Approving the requested resources will result in the following support EMSA's mission and goals improve sustainability of pre hospital EMS equity and social justice efforts with state, local, private, and community based organizations improve EMS patient outcomes in disadvantaged and disparate communities across the state and align with the CalHHS mission of creating patient focused programs addressing access, treatment, and work streams to combat EMS healthcare disparities and workforce inequities.

Thank you turning over to Department of Finance Raleigho for any comments.

Sonal Patel, Department of Finance nothing to add.

We have no concerns with this proposal.

Any comments? See none. We're going to hold the item open. Move on to issue number four. California Post E Registry Act, Trailer Bill Language joining us on Zoom is Deputy Director Lorna Eby.

Thank you. MS is proposing to strike through the statutory requirement to integrate the Advanced Healthcare Directive Registry into the POLST eRegistry. The POLST form is a medical order signed by both a patient and a physician, nurse practitioner or physician assistant that gives seriously ill patients more control over their care by specifying the type of medical treatment they wish to receive towards the end of life.

Chapter 143, statutes of 2021 or Assembly Bill 133 enacted the California POLST eRegistry, which requires EMSA to establish a statewide electronic POLST registry system for the purpose of collecting patient pulse information and providing real time electronic access to the form by EMS and medical providers.

AB 133 also requires EMSA to incorporate the Advanced Healthcare Directive Registry, established pursuant to part five of division 4.7 of the Probate Code and overseen by the Secretary of State, into the POLST eRegistry.

As there is no existing electronic registry for the AHCD, integration of the AHCD or Advanced Healthcare Directive data into EMSA's electronic registry is not feasible without significant delays to the implementation of the POLST eRegistry and additional funding. Eliminating the requirement of EMSA to incorporate the AHCD registry into the POLST Registry will allow the system to be implemented in a much more timely manner.

There's a follow up question that you asked, and I'm going to pass that off to Lorna Eby of the Office of Systems Integration, who is the project lead as we wind through the PAL process on this.

Hi, good afternoon, Madam Chair, honorable Committee Members, and thank you, Mr. Trussel. I will address question number two, which is please briefly describe the operational challenges to including data from the Advanced Healthcare Directive in the POLST Registry. Beginning in about February of 2022, as part of the project planning for the ePOLST Registry, EMSA, in collaboration with OSI, began discovery on the current status of the AHCD registry in California and requirements for its inclusion.

I should note at this time that OSI provides both project management, procurement and ongoing systems of support to departments within California Health and Human Services Agency, and that is the capacity in which I am sharing these observations. The following operational consideration and challenges were identified.

As previously mentioned, there is no existing electronic registry for the AHCD in California, so it needs to be developed from scratch, which means incorporation of AHCD data is not feasible without significant delays to the implementation of the ePOLST Registry.

The POLST form is materially different in both form and intent from the AHCD. The POLST form is a brief, two page, standardized medical order designed for persons who meet specific healthcare criteria such as advanced disease or illness or frailty. It specifies very specific life sustaining treatment and wishes, and it is immediately actionable and usable in the field by EMS personnel.

The POLST form has defined data fields and specific orders that are directly relevant to care provided by EMS and lends itself to conversion into an electronic format. The POLST form is completed and signed by a medical professional and lends itself to digital signatures and is included as part of a patient's healthcare record.

An AHCD must be signed by two witnesses and or notarized. EMSA has clear authority for POLST, whereas authority for the AHCD rests with the Secretary of State currently by statute.

One important note is that section D of the POLST form does allow the patient to indicate if they have an AHCD and who their agent is representing them. As mentioned, while many healthcare providers provide AHCD forms for patients, it is not standardized and probate code permits an AHCD form to be modified in any way necessary and alternative formats to be used. As a result, many providers have created their own versions of the form and all versions can be modified by the patient.

While a POLST form is a medical order designed and put in place between a medical practitioner and the patient. The AHCD is a legal document and is uniquely developed by an individual, often with their attorney, and unlike the POLST form, it covers an array of end of life wishes that go beyond life sustaining treatments, in emergency situations. The form may be many pages in length, and this creates challenges in digitizing an AHCD document as well as challenges with usability by EMS personnel.

Unlike a POLST form, which is targeted for a specific patient population, any competent adult can have an AHCD. We know that the Secretary of State has approximately 10,000 AHCDs on file, but we do not know the total number of advanced directives that may exist within California at this time.

Also, because of the nature of the AHCD, it is incumbent currently on the patient by process or the individual, I should say by process, to ensure that their form is maintained in a current state in the registry.

Because the AHCD is not standardized, it can express general and or specific healthcare wishes, such as designating a power of attorney and pain management, and it is not necessarily actionable by EMS personnel. Because of the breadth and scope that an AHCD may take, maintaining the AHCD registry and responding to questions from patients and healthcare providers may fall outside of EMSA's mission, authority and current expertise.

The AHCD is used by a far broader cross section of health providers in a variety of settings, including long term care and skilled nursing. It should be noted that security requirements for ePOLST may be different from AHCD registries due to ePOLST being in medical order and subject to PHI. As previously mentioned, it is contained in the patient's medical record, we would need a thorough understanding of HIPAA and other security requirements for each form.

The coupling of the AHCD with ePOLST introduces complexity from a legal policy and technology perspective that would have to be resolved before the ePOLST Registry could move forward. Because the POLST form is a well defined, standardized medical order that currently is an existing responsibility of EMSA.

Decoupling the requirement for EMSA to incorporate the AHCD registry into the POLST Registry will allow the ePOLST Registry to be implemented under the current timeframes and budget, and with that, I will take a pause.

Thank you so much. First, turning to Department of Finance in LAO for comment.

Nothing to add? Thank you.

Nothing to add.

Two questions on my end, Deputy Director Lorna, you mentioned, EMS. It's life sustained treatment where their advanced directive doesn't always come into play. So can you talk to me a little bit more? Can you share a little bit more regarding how this is the reason why it shouldn't be connected. And then second, the POLST. Not everyone has a POLST either that you can reference. And what if that individual you're treating has directive in the advanced directive for do not resuscitate?

How do you then combat that? Those two questions.

Yes, I will be glad to take an opportunity to address that, but I will also invite Mr. Trussell to weigh in from a programmatic standpoint. And please help me make sure that I'm addressing your question as phrased. So a POLST form is, in many ways, can be considered a subset of an advanced care directive. It is targeted to a very specific population.

It is two pages in length, and section B of the form outlines very specific medical interventions that a person may or may not want to have by healthcare personnel, EMS personnel, in an emergency situation. So it differs from a healthcare directive, an advanced directive, in that regard.

Whereas a healthcare care directive can take on many formats and can address an array of different types of end of life wishes that may or may not include POLST, any competent adult can have an advanced care directive again, versus an ePOLST, or versus a POLST form, which is designated for a specific population based on medical criteria that is noted and developed between the patient and their physician. I will take a pause there to see if I'm missing any elements of your question, Madam Chair.

And I may need to invite Mr. Trussell to weigh in on the DNR question.

Thank you.

Can you repeat the question, ma'am?

Yeah, I'm wondering, I guess this was before my time, as to why it was implemented, to transfer the information from the advanced directive into post. If you're in an emergency situation, it's life sustaining treatment. How does that come into play, that you need that document right then and there?

Well, I think as part of the overall goal of medical record high HIE, or the health information exchange, is that the EMS personnel would have direct access to this form, so they can either provide the medical treatment or not provide the medical treatment at the scene. An AHCD, however, could be a huge document where they don't really have the ability to go through the document and note everything while they're providing the emergency support services.

So to have the AHCD right now, there's really no streamlined AHCD process where these items can be brought up. And since right now, my understanding is the AHCD is essentially submitted by an individual, there's no proof that it's been submitted by an attorney or it's been validated that it is an AHCD. And so it's just sitting there for access from doctors, providers that they call up and they access it through the Secretary of State's office.

So really the POLST registry is being designed to be an emergency services tool when providing treatment.

Thank you, Senator Ruth.

Well, are you saying that if there's an advanced directive prepared appropriately and the formality is done that a healthcare provider can ignore it when a patient is presenting?

No, I'm not saying that. But the ePOLST Registry form would be part of the patient record.

Right no, I understand. So let me ask this. We're designing a statewide electronic registry system to collect information, and in this case it was primarily to deal with the POLST issue. But it would seem to me that what you really need to know if you're in the field is whether there's an advanced directive that says do not resuscitate, right?

Correct.

All the rest of the stuff at that point probably irrelevant to the process. Right?

Correct.

So instead of worrying about whether we can export this entire form into some electronic system, a form that apparently deals with a lot of other things besides the do not resuscitate.

Seems to me all we need to have added to your statewide electronic registry system is whether there is a form that the Secretary of State has that includes a do not resuscitate, right?

Correct? Yes.

So why are we talking about that? Because if I'm a patient and I've signed an advanced directive with all the legal formalities that the probate code requires, and maybe I've sent it to the Secretary of State, I don't know.

And I have an EMS unit there with a paramedic and an EMT and they're ready to paddle me, but they can look up on whatever you put in the units that says, I may not have a pulse, but I have an advanced directive that says Richard Roth, do not resuscitate. And it's coming from some government repository that says that. Wouldn't that be helpful?

It would be helpful. Yes.

Comment. Excuse me, Senator, may I add comment to this question.

To the chair?

Go ahead.

Madam Chair, may I add comment to this question?

Go ahead.

Thank you. I appreciate the opportunity. The POLST form itself, as mentioned, is a very brief two page form, and section B on the very first page of that form outlines the medical interventions that a person, if they are found with a pulse and or breathing on scene, that they would want by EMS personnel, including full treatment, selective treatment, or comfort focused treatment only. So that allows an EMS personnel to very quickly scan that form.

And as long as the form is fully complete and all sections are completed and it is signed, they can take that action immediately in the field versus an advanced directive, which because of its breadth and scope, it may or may not contain these types of directions. It could have power of attorney, for example. It could have are more limited or more expansive directions on the full scope of end of life versus life sustaining intervention.

So I think that is one of the material differences that again, part of what we're saying is, would require that more deeper discovery. And because the POLST form itself has this very focused and again, by EMS personnel or emergency personnel, that could include doctors in an emergency room situation as well, because it has that again, very dedicated and specific focus for a specific population, again, that they would have, that it would allow, again, a readily used and immediate intervention by EMS personnel.

And certainly I think we're all in agreement that advanced directive does contain important information as well. We are trying to outline, though, the challenges and the additional discovery and conversation that would need to be had to make that form as usable for this type of, not just registry, but also electronic format that we're speaking to.

Well, listen, I understand the differences between the two forms, but I also understand that if someone executes an advanced directive that says do not resuscitate, they expect medical personnel responding, assuming it's appropriately executed and appropriately disposed of, wherever that disposition is, they expect medical personnel to adhere to the request.

So what you're suggesting is perhaps we need to reopen the probate code and in addition to the advanced directive form that we currently provide for, I guess we need to provide the simplified version if you need a form in your system, as opposed to an entry, the simplified form so you can add it to the POLST requirements. So I guess this is just my opinion. From my perspective, you probably ought to keep the stove warm on the statewide electronic registry system.

So if we're able to get a simplified form through the Legislature and through the governor's office, that you're able to implement it, because I may not have a pulse, but when the EMTs show up and the paramedics show up at my house, if I say do not resuscitate, I don't want to see paddles, assuming I can see. Right.

So let's see if we can come up with some suggestions and take some action to make sure that whatever is in the directive, if it pertains to do not resuscitate, is in your system, if that's what we're telling paramedics and EMTs that they need to look at to decide what they need to do with respect to treatment within the protocol. Thank you. Thank you, Madam Chair.

Thank you Senator Roth, Senator Eggman, thank you.

And my comments are along the same lines as Senator Roth. So you got two old soldiers and one young soldier up here. And it sounds. Sorry. And it sounds like at least two of us up here have advanced directives with our wishes known that we don't want the paddles because we are ineligible to have a pulsed order because we don't have a certain diagnosis that would ineligible make us eligible to have a pulsed certificate or a form filled out.

So I would agree that we need to find some way to blend those two systems. Otherwise, we're developing a system for a very small population that first responders are responding to for people who are already very ill.

These are already very ill people you're going to go see versus the general public who also want to be included in our wishes being known, especially if we've gone through the trouble like the general hoping I turn it into the Secretary of State and it's not just in my file cabinet, but as a hospice social workers, that's what we would tell people. You got to tape it to the refrigerator.

So I'm very glad we're not taping things to the refrigerator anymore, but we need to find a way to combine these two systems so that people's wishes are able to be respected at the end of life.

Thank you so much. For now, we're going to hold this item open and move on to issue number five. The EMSA Director and Chief Medical Officer Trailer Bill Language.

Sonal Patel, Department of Finance. The Administration is proposing to remove the medical doctor requirement as a part of the eligibility criteria to serve as the department's director and to appoint a Chief Medical Officer.

Existing law requires EMSA's director to be a licensed physician and surgeon with substantial emergency medicine practice, and these requirements have limited the eligible candidate pool and made it very challenging to recruit for this leadership role in the past.

Therefore, removing the MD requirement for EMSA's director will assist the department with tapping into a broader candidate pool while at the same time focusing on the appropriate skill set with regards to public Administration for the director. And I'll also respond to the second question.

In terms of the bifurcation of duties between the director and the CMO, the Administration's perspective is that by removing the requirement for the EMSA director and adding a medical officer, this really allows for the director to continue to focus on the day to day operational, administrative and strategic planning activities that are really necessary for the chief administrator of a department. On the other hand, the CMO would have oversight of clinical functions that have a direct impact on patient care, patient safety, and patient outcomes.

As a couple of examples of what the CMO would have leadership over, that would include approving revisions to standard scopes of practice for EMS providers. That would also include final approval on local EMS agency EMS plans over which there is a clinical care component.

Specifically, those areas include emergency medical dispatch as well as special EMS clinical program plans. Another potential duty of the CMO would be oversight of EMSA when they're in the field, their response activities as it relates to disaster medical services.

Any comment?

No comments on this proposal.

No comments from me. We're going to hold that item open, and that was the last issue in the Department of EMSA.

Thank you. Thank you.

The last Department we'll be hearing from today is the Department of Public Health. I welcome the Administration will be presenting to come on up.

Thank you.

The first issue here is just going to be an overview, not just, but will be an overview of the Department of Public Health.

Thank you, Madam Chair. Am I turning you off? Sorry. Okay, got it.

Before we move forward, we're going to do a State of the State's Public Health.

Okay, that will be me. Good afternoon. My name is Dr. Tomás Aragón. I'm the state public health officer and Director of the California Department of Public Health. It's an honor to be here today to present on the State of Public Health in California.

At CDPH, our mission is to advance the health and well being of California's diverse peoples and communities with the vision that all Californians enjoy healthy communities with thriving families and individuals. Health is not the absence of disease or injury.

It's a state of complete physical, mental, and social well being. The Institute of Medicine defined public health as what we as a society collectively do to ensure the conditions in which people can be healthy.

Public health is our collective endeavor to protect and promote and improve the health of our communities. Unfortunately, the field of public health is often misunderstood and sometimes confused with health care, which is a provision of medical services to a predefined population. Here is a public health approach. It has four pillars.

First, the ecological social, also called ecosocial, which is a relationship of people with their family and social networks and with their neighborhood and environment. In other words, health happens where we live, work, learn, play, and pray. Think, for example, of the Covid-19 pandemic and its widespread impacts.

Think of the health impacts from climate change. The second pillar is life course and intergenerational processes. Think of adverse childhood experiences and toxic stress and the intergenerational transmission of the social and biological effects of adversity and trauma.

The third pillar is equity and health equity. Think of low income communities and essential workers with high rates of Covid-19 exposure, illness, hospitalization, and deaths. Think of the disproportionate impacts of violence and mental health on communities of color, especially black African Americans.

And finally, the fourth pillar of public health is a prevention focus, especially primary prevention. Think of laws reducing availability of tobacco products and exposure to secondhand smoke.

Think of smarter street design, vehicle standards, seatbelts and child safety seats, and robust safety mobility options to reduce road fatalities. Well, what have we accomplished collectively? Over the last 20 years, public health has contributed to significant improvements in health and well being for all groups in California.

For example, the death rate for lung cancer has decreased by 57% since 2001 thanks to comprehensive tobacco control efforts. Creating a social and legal context in which tobacco is less desirable, acceptable, and accessible.

The HIV death rate decreased by 71% between 2001 and 2021 for all groups and by 73% for black individuals. Birth rates among adolescents decreased by 78% between 2020 due to improved access to public health prevention strategies, including comprehensive sexual health education, clinical services, and promotion of healthy relationships and communication practices. Despite declines in mortality for all groups in California, significant racial and ethnic health disparities continue.

For example, overall life expectancy is 10 to 12 years less for black individuals compared to Asian individuals with the highest life expectancy. The rate for alcohol related deaths is 14 times higher for American Indian and Alaskan native individuals compared to Asian individuals and is the fourth leading cause of death for this group.

The pregnancy associated mortality rate is about 3.5 times higher among black women than among white women. HIV STD death rate is 11 times higher for black individuals than Asian individuals.

Public health works to reduce these disparities by informing policies that address the underlying social, environmental, and behavioral drivers of health and by regulating selected sectors with high impacts on health. For example, we license and certify and inspect over 10,000 health facilities across California.

Equity is a foundational, guiding principle in public health. Based on need, every Californian should have the resources and opportunities to be healthy and thrive. This requires prioritizing investments in communities with continuing health inequities.

Today, California faces some of the toughest public health challenges in decades. These challenges include Covid-19 chronic diseases like cardiovascular disease and Alzheimer's, mental illness and substance use disorder, firearm related death and injury, and health impacts from climate change and extreme weather.

CDPH is building capacity to tackle these public health priorities. Climate change is a major force impacting the public's health, affecting all aspects of our health and well being affecting access to clean air, food, water, shelter and physical safety.

Heat waves, droughts, wildfires and wildfire smoke and flood result in illness, injuries and deaths as well as loss of livelihoods contributing to unemployment, poverty and housing instability.

Direct and indirect effects increase chronic and infectious diseases, mental health challenges, and heat and smoke related illnesses. The impacts have the greatest toll on the health of those already experiencing health, social and economic inequities.

Public health monitors population health impacts and partners with state and local government and the private sector to embed the public health approach in efforts to address these challenges. Life expectancy steadily increased for 20 years prior to 2020, but due to impacts of the Covid-19 pandemic, we experienced a sharp drop in life expectancy. In 2021, Covid-19 was the leading cause of death and years of life lost with over 43,000 Californians losing their life in the year of 2020.

Millions more experienced severe illness, hospitalization, disruption to education and work, and sometimes loss of jobs or housing. Covid-19 highlighted and exacerbated existing health inequities.

The Covid-19 death rate was significantly higher for native Hawaiian and Pacific Islanders, blacks and Latinos compared to the statewide rate. Low income communities suffered disproportionately. They live in crowded conditions, work in essential frontline jobs, and had more exposure to Covid-19.

They had less access to resources, creating gaps in healthcare information, housing, and economic security. Through our collective actions providing testing, vaccination, treatment, and public health guidance cases, hospitalizations and deaths dropped significantly between 2020 and 2021. In 2022, Covid-19 dropped to be the third leading cause of death.

Now, in 2023, we have reached the lowest level since the pre pandemic period, enabling activities of daily life to resume more safely. Covid-19 will remain with us for the foreseeable future, including the uncertain burden of long Covid.

Using lessons learned from the pandemic, the California Smarter plan enables us to manage Covid-19 today and to prepare for future surges and variants, as well as to respond to emerging infectious diseases. Last year, CDPH leveraged the COVID response infrastructure and the Smarter plan to respond to the mpox outbreak.

We were able to activate systems for surveillance, vaccination, and treatment to highly impacted communities. 14 day average case rates have fallen from more than 90 per day in August 2022 to less than one case per day.

CDPH distributed vaccine and antiviral treatments statewide, supported vaccination events, and provided disease prevention messaging. Almost 300,000 vaccine doses have been administered to more than 180,000 people, with over 100,000 persons receiving two doses.

Again, at the end of 2022, we leveraged the new Covid response infrastructure to address the simultaneous surge of Covid-19, Influenza and RSV. We tracked disease level and real time and projected impacts on the healthcare system. CDPH provided data to local partners and policymakers to guide the response to this triple demic.

The Governor's 2023 Budget proposal continues investments to support the state's effort to protect against Covid-19 and other public health impacts. California's population is growing older. By 2031, one in four Californians will be over the age of 60.

Ischemic heart disease and Alzheimer's disease continues to be the top leading causes of death for Californians. Cardiovascular diseases contributed to the most deaths in 2021. This condition groups include ischemic heart disease, stroke, and hypertensive heart disease, all of which are the five leading causes of death.

During the pandemic period, rates of ischemic heart disease increase, countering the long term trend of decline. The data for 2021 shows that the downward trend has returned, reaching an all time low. Most cardiovascular conditions can be prevented by addressing behavioral risk factors such as tobacco use, unhealthy diet and obesity, physical inactivity, and harmful alcohol consumption.

However, recognizing that deeply rooted social and economic inequities are the drivers of many health behaviors, public health informs policies that improve community conditions so all people can enjoy safe, walkable neighborhoods and access to healthy foods and affordable housing.

Deaths from Alzheimer's disease have more than doubled since the year 2000, and about one in 10 adults in California experience objective cognitive decline or memory loss.

CDPH collaborates with stakeholders to support the master plan for aging to prevent and prepare for the growing number of Alzheimer's cases and forge a path forward for families. Several conditions other than Covid-19 show substantial increases in death rates over the past two years.

These include deaths related to alcohol, roadrage injury, and drug overdose. Drug overdose has by far caused the largest increase, with deaths increasing by over 200% between 2011 and 2021. This began with a 63% increase in the pre pandemic period.

This increase surged dramatically during the pandemic period, with an additional 79% increase in just two years in just two years and over 10,000 deaths in 2021. In 2019, drug overdose deaths overtook ischemic heart disease as the top cause of years of life lost.

Between 2019 and 2021, there was also a 38% increase in homicides after many years of decreasing or level rates. This was driven by an increase in firearm related homicides. Exposure to gun violence traumatizes survivors and communities, impacting mental health and social well being.

Many public health challenges start early in life among children, youth, and young adults, impacting their life course, trajectory of physical, mental and emotional health and well being. Children and youth are dealing with unprecedented challenges due to the Covid-19 pandemic.

As of September 2022, almost 38,000 California's children under the age of 18 had lost a parent or caregiver due to Covid-19 this type of loss has long term health consequences and contributes to adverse childhood experiences or ACEs.

Toxic stress over time from ACEs can alter brain development and affect our body's response to stress. ACEs are linked to chronic health problems, mental health issues, and substance misuse in adulthood. In California, about six in 10 adults report experiencing at least one ACE before the age of 18.

Public health works with the Department of Social Services and the Office of the Surgeon General to promote policies that prevent ACEs and build safe, stable, and nurturing relationships and environments through programs like home visiting.

Mental health conditions affect more than half of US people over their lifetime and contribute to worse overall health and risk of death by suicide. In California, severe mental illness and substance use disorders have a significant impact on young adults, with mood disorders and schizophrenia as the first and third leading causes of hospitalization, respectively, for Californians aged 15 to 24.

Mental health conditions are the second leading cause of years of lived with disability for Californians and the leading cause for children between the ages of 5 to 14, emphasizing the need to strengthen prevention, early identification, and compassionate care.

Untreated mental health problems or substance use and addiction can result in injury and premature death. In 2021, over 4000 Californians died by suicide. The overall number of suicide deaths has decreased since 2018 because of decreases in older persons.

In contrast, suicide and self harm are among the top five causes of death for 15 to 44 year olds, and rates have been rising in recent years among black and Latino Californians. Hospitalizations and emergency department visits for mental health related conditions are higher among black individuals than for any other race or ethnic group.

The Governor's Proposed Budget demonstrates a steadfast commitment to advancing the health and well being of all California's communities while prioritizing the most vulnerable through critical investments in the behavioral health system, social system, social safety net programs, and public health infrastructure.

Recent public health efforts aim to prevent addiction and overdose through harm reduction strategies, public awareness and education, recovery and support services, as well as innovative approaches to make naloxone and fentanyl test strips more widely available.

The California Youth Behavioral Health Initiative, an interdepartmental, collaborative effort to transform the behavioral health system to be more responsive to the current needs of our children and youth, is a major focus for us. CDPH is leading an educational campaign to normalize seeking support for mental health challenges and to destigmatize behavioral health in communities.

The budget provides support for core public health infrastructure through the Future Public Health Initiative, the state invested $300 million to modernize state and local public health infrastructure and to transition to a more resilient system.

Centered on equity, we are building our capacity and capabilities in long term strategic planning and policy development, workforce development, data modernization, data science and decision intelligence, emergency preparedness and response healthcare partnerships to improve population health management, community engagement and partnerships and recruitment and retention of a diverse workforce that reflects the communities we serve.

This funding is already at work, with many new staff hired across the state to support this transformation. CDPH is an agency with over 220 programs and over 4000 staff. But public health is what we do collectively to ensure the conditions in which every Californian can be healthy and thrive. Thank you for your leadership and support.

Thank you so much for that. Sometimes hearing these stats, it weighs heavy on you. And I appreciate you also tying the gun violence with public health that oftentimes isn't looked as it being linked together. So I appreciate that. Any comments before we dive in?

Just one question. Always nice to see Dr. Aragon. How is it going with collecting the SOGI data now? I'm speaking as the chair of the LGBTQ caucus, but also has to do with budget. So some of that data that we have been asking for, it's been slow to come.

The funding for the MPOCs that we provided never went out, and we got the crisis under control. And I know there's been a pandemic. Right. But there's also angst amongst some of my members.

Yeah. So for the SOGI audit, we just completed an audit, and we just had the review with the team on Monday. And so there's detailed recommendations in the audit and definitely an area of improvement for the Department of Public Health, and so we're committed to making those improvements.

Okay. and the MPOCs?

I have to follow up on the detail of that budget. My understanding is that the money did go out, and when the rest of our team comes out up, they may have more information on that. Okay.

Okay. Because my understanding was we allocated for that, but then it didn't go out.

I think. And then.

So we had to reallocate it somewhere else.

Yeah. And I think when we start to talk about some of the COVID issues. Apologies. Brandon Nunes, Chief Deputy for Operations at the Department. Probably that team will be able to have some discussions with you about the Monkeypox, the mpox rather investments that went out.

Thank you.

Thank you, Senator Eggman. We're going to move into another overview. Well, same overview. Department of Public Health. You said, Brandon?

Yes, ma'am.

Welcome.

Thank you. Yes. Brandon Nunes, Chief Deputy for Operations. Since Dr. Aragon pretty much gave a program overview, I'll just give you a really high level budget overview for our department. Your agenda does a great job of highlighting it for us.

But overall, for our department, for 23-24 we have a budget of 5.5 billion that's broken down by $1 billion General Fund, 2.2 billion federal funds, and 2.3 billion from about 50 different special funds in the department.

We also provide 3.5 billion in local assistance funding, and then 2 billion of that stays with the department. As Dr. Aragon mentioned, our budget does include the investment from last year, the 300 million for future public health.

100 million of that stayed here with the Department, and 200 million was provided to the local health jurisdictions for their infrastructure as well. Our budget does assume reduced Covid response cost. That's in part driven by reduced response activity since the peak of the COVID response.

As a result, our 22-23 projected expenditures are being reduced by 614 million in the current year. And then we do have investments of 176 million in the budget year 23-24 to implement Covid response, roughly 100 million for that. And then implementation of our Smarter plan, about 75 and a half million, roughly, is for that, primarily for maintenance and operations of some of our systems that were stood up during the COVID response.

And we're prepared to chat with you a little more when we get to issue number two today. On those with our team, we do have a couple of areas in our budget that are part of the Administration's strategy to address the budget shortfall. One of these areas is related to the public health climate and health resilience planning grants that were provided last year. This does fall into the category of the Administration's trigger reduction.

So to the extent there's funding in the 24-25 budget, this particular reduction would be restored. And then we do have a partial public health workforce reduction that we'll be talking to you about today. In issue four, I believe roughly the budget reduced funding for various public health workforce training and development programs by roughly 49.8 million. This is split over four fiscal years, with about 5 million coming out of current year and about 20.8 million in each of budget year and budget year plus one.

And then finally, we do have a number of different BCPs and proposals we'd be talking to you about. Over the budget season, the Governor's Budget included about 14 million, that's total funds to support about 15 pieces of legislation that passed last year. We have about $3.2 million in increases that come from our Proposition 99 and our Proposition 56, our tobacco tax funds to support our tobacco cessation programs.

And then finally there's about a $200 million increase in the current year and roughly a $220 or so million increase in the budget year to support our public assistance programs, such as our Age Drug Assistance Program, our Genetic Disease Screening Programs, and of course, our women, infants and children programs.

That's a very high level overview of our budget. We, of course, have our team here to talk about a lot of these issues, but happy to stop there and take any questions.

I have a question, and I think maybe either of you. Dr. Aragon, you mentioned a little bit about STI. I apologize if I missed this. The CDC just came out with some statistics on youth STI rates have gone up and our youth have decreased the usage of condoms, especially in our rural areas. Just want to know if your team has been able to look into that most recent CDC report. Early conversations regarding that.

Later on, James White, I think he's going to be presenting later on from the Center for Infectious Diseases. He can tell you the latest.

We'll be prepared for that one.

Perfect. Okay, then we're going to move into issue two, the Covid-19 response.

Thank you.

You. Is this on? Okay. Good afternoon, Madam Chair and Members of the Subcommitee. My name is Melissa Relis. I'm the assistant Deputy Director of our Emergency Preparedness Office at the California Department of Public Health. So, for budget year 23,24 CDPH is requesting $101.3 million to continue the state's public health and safety response efforts against Covid-19 the funds will support priority pandemic response efforts through June of 2024. Specifically, CDPH is requesting $28 million to purchase test kits for vulnerable populations.

We've included $15 million for operations support, which includes consultants and redirected state staff, in order to support CDPH's continued response for activities that include vaccines, therapeutics, testing, and distribution of supplies. CDPH will continue service agreements for the Medical Health Coordination center and the CDPH warehouse to support response to and recovery from the pandemic and finally, ongoing legal settlements for Covid-19 related litigation, including challenges to state public health orders and guidance.

Also included is $5 million to provide grant incentive programs that support pediatric providers for administering vaccines to children under five and $3 million for the provider call center and technical assistance for local health departments and providers. There's also $300,000 to support IT infrastructure. And finally, should it be needed, CDPH is requesting $50 million in emergency contingency funds to support pandemic response efforts that exceed the already identified areas of need. And I can pause there or I can go right into the question.

Please go into the question.

Okay, so the rationale for the reductions although CDPH received nearly $1.8 billion in the current year for Covid-19 response activities, we are reflecting a proposed budget adjustment reduction of $614,000,000 to meet this budget adjustment in current year, CDPH plans to reduce spending in many areas of the Covid-19 response, including public testing activities, therapeutics, and state operations support. Additionally, CDPH no longer plans to utilize the $250 million contingency Fund that we were authorized to spend this year.

In addition, the current year budget includes over $400 million for the border response efforts in Southern California, which is not in the CDPH request for funding in budget year. And for this request, CDPH is requesting again $101.3 million in 2324 as we anticipate many of the ongoing Covid-19 response efforts to either wind down, such as the gradual demobilization of community testing sites, the public testing lab network staffing deployments, and many other activities to transition to the healthcare system, such as therapeutics and vaccine Administration.

CDPH also plans to reduce our Covid-19 response activities by reducing our wastewater surveillance footprint and lab testing capacity, reducing our monitoring of the impacts of long Covid and other long term impacts of the pandemic, reducing our case investigation and contact tracing teams training and ability to surge with deployed staff. One of the most significant reductions is testing. Previously, the testing effort focused on supporting community testing sites, schools and other outbreak response needs, as well as purchasing overthecounter antigen tests.

This request scales our testing response to purchasing a smaller amount of overthecounter antigen tests for vulnerable populations. CDPH's surveillance and epidemiology capacity will also scale back with a reduction in reporting frequency, less detailed epidemiologic information, and less hospital and vaccine data reporting.

In addition to decreasing our automation and data integration capacity, as well as scaling back our modeling and advanced analytic capacity, this request for budget year prioritizes the most critical activities that need to continue so that California's most vulnerable populations are protected and to maintain a State of readiness.

Turning over to Department of Finance, LAO for any comment.

Hi, yes, Will Owens, LAO. So we just want to note that we believe that ensuring the Department has sufficient resources to respond to any developments in the Covid-19 pandemic is prudent. However, we would note that the Legislature may want to consider and weigh the need for dedicated contingency funding, especially in the year of budget solutions.

We would be happy to work with the Legislature to consider alternative budget language to allow for the spending of funds for developments, as well as to strengthen legislative oversight of those additional funds.

Thank you so much. Just clarification on the staffing. I mean, this is the first time we've talked about workforce shortage. This is the first line item. I see $0 here. You spoke about the outreach teams. Is that why? Because you're pulling them back in. You no longer need that section?

Okay, so we're looking at, I'm sorry.

Staffing.

Okay. Right. That was our med surge staffing, and so we're significantly scaling that operation back.

Senator Eggman.

What do you mean by your med surge? Like people who are on the wards and stuff?

People in hospitals and healthcare facilities.

Okay, that was just for that part. Okay. All right. And I would just like to the chair to make sure we work with the LAO. I'm also uncomfortable with. We were caught a little flat footed, and I know public health thought they were going to get a whole lot more money than the budget allowed for you.

And so it doesn't seem to me to be prudent to be pulling back anything from public health when we know we still have STD issues, we still have suicide issues, we still have a lot of issues that directly relate to public health. So it just doesn't seem to me to be prudent for this to be an area that we cut back on. And I don't know if the Department has followed.

You probably have some of the first rounds, they're doing massive assessments of young people and their behavioral health needs and what they would like to see. And some of the things are just more like things that we may take for granted, like fresh air, having places to play outside, having activities. So those kinds of things that I see much more related to public health.

So I certainly hope there's a role for the Public Health Department as we go forward with new plans of standing up a whole platform for our young people's mental health needs.

Thank you. We're going to leave this item open, and we're going to move on to issue number three, maintenance and operations of infectious disease data systems, the smarter plan. We're joined on Zoom by James Watt, the Assistant Deputy Director from the Center of Infectious Disease, Department of Public Health.

Good afternoon, Madam Chair and Committee Members. Can you hear me all right?

Yes.

Thank you very much. I'm glad to present to you this afternoon. The California Department of Public Health requests $74.4 million in General Fund in 2023, 24 for the maintenance and operations of critical infectious disease data systems established during the Covid-19 pandemic that will continue to support the state's emergency preparedness and response efforts and disease control work for Covid-19 and other infectious diseases.

This funding will support maintenance and operations of two important systems, the California Covid Reporting system, or CCRS, which has been renamed SAPHIRE and Cal Connect the state system for disease investigation and contact tracing, as well as IT infrastructure and security costs. So I will briefly describe these three items. First, CDPH requests $30.9 million in 23,24 for maintenance and operations of SAPHIRE, which stands for the surveillance and public health information reporting and exchange.

SAPHIRE is a core element of the system that CDPH uses to collect data on all reportable diseases. SAPHIRE enables CDPH to receive electronic data messages from laboratories and other data submitters. This system is critical to disease prevention and control efforts for Covid-19 and other infectious diseases, as well as preparedness for future pandemic and emergency response. More than 350 data submitters are connected directly to the system and submitting results on behalf of thousands of entities.

CDPH received an appropriation of $26.3 million in 22,23 to provide one year funding to support and operate the system. The one year funding strategy was designed to allow CDPH to obtain updated maintenance and operations costs through a recompetition for the system. In 2022, CDPH engaged in a new challenge based procurement process, resulting in a contract with a new vendor.

The transition between the old and new vendor was completed by December 31, 2022 and as part of the transition, the system was renamed to SAPHIRE to recognize that it receives data for all reportable conditions, not just Covid-19. Second, CDPH requests $39.7 million for 22,23 for 23, 24 for maintenance and operations of CalConnect. Calconnect is California's system for case and outbreak investigation, contact tracing, monitoring of exposed individuals, and communication with affected persons.

Cal Connect was developed during the pandemic and has now been expanded to support the M Pox response. It has also been utilized for monitoring persons exposed to Avian influenza and Ebola virus disease. CDPH plans to leverage the Cal Connect functionality to address other priority conditions that require case investigation and contact tracing, such as tuberculosis, HIV, syphilis, perinatal, hepatitis B, and measles. CDPH received an appropriation of $39.6 million in 22,23 to provide one year of funding to support maintenance and operations of Cal Connect.

The one year funding strategy was designed to allow us again to update costs for Cal Connect through a recompetition, which we did in 2022, resulting in a new contract with the existing vendor. Third, to support data system modernization efforts, CDPH requests $3.8 million in 2324 for licensing, maintenance, and support of the infrastructure and security protocols needed to support the public health surveillance and response systems and departmental data, including confidential protected health information.

The funding requested in this proposal is needed to maintain and operate CDPH technology infrastructure in its current state, support critical public health services statewide, prepare for and respond to future public health emergencies, and to leverage the technology developed for Covid-19 to address other conditions that impact the people of California. Thank you. And there was one question that I'm happy to answer as well, or if there are other questions now I can pause.

Go ahead and answer that last question.

Great, thank you. So the question was the requested maintenance and operations resources are only for 23,24. What is the plan for ongoing maintenance and operations of these systems? So these two systems are in maintenance and operations now, and they're planned to be an ongoing part of the CDPH portfolio of IT systems used to monitor and control reportable diseases we plan to refine future cost estimates as we are working on a Department wide it strategic planning process in conjunction with the future of public health planning.

So we do anticipate submitting a future funding request based on these refined cost estimates.

Thank you. Department of Finance or LAO any comment?

Sanol Patel, Department of Finance nothing to add right now.

Will Owens LAO no comments on this proposal.

Okay, James, quick question here. All the requests here. Do you have the workforce in place to meet the maintenance for the year.

For the two systems?

Yes.

We did receive funding for the workforce for these systems in a previous proposal, and so we are in the process of bringing those people online. We've already brought on a number of folks, and we're continuing that process.

Senator Eggman, anything? Great. Thank you so much, James. We're going to hold this item open, and we're going to move on to issue number four, the public health workforce investments reversion. Welcome.

Hi. I'll give a quick summary of the changes. Susan Fanelli, Chief Deputy with public health the proposal eliminates $5 million in current year funding of the 20.8 million for these pipeline programs. It does not include the first one on the list, which is the public health nurse certification fees. That's not part of this one. But it does include the pipeline programs, including the upskilling career ladder funding, the pathways program, the microbiologist training, the lab Director training and the epidemiologist Cal-EIS program.

And so we are in the process, in current year of allocating these funds out. We have plans for the current year funding, but it does eliminate funding for the pipeline programs in the coming years. It was promised over. The original recommendation was 20.8 million in funding over 23,24 and then 24,25 and again a smaller amount in the fourth year. And so this would eliminate that funding.

And I'll let finance talk about sort of the tough choices that had to be made with prioritization of the ongoing future of public health funding. The 300 million. But happy to take any questions.

Turning over.

Good afternoon, Madam Chair. Nick Mills, Department of Finance a key component of the administration's approach to addressing the budget problem was to prioritize ongoing commitments approved in previous budgets, including those commitments for public health infrastructure and staffing resources, which, of course, include 300 million General Fund ongoing for state and local health departments, a large portion of which was for new staff, as well as ongoing workforce and not skilling programs included in last year's 21st century public health it proposal.

Go ahead.

Yes. Will Owens, LAO so we just wanted to note that the Legislature may wish to evaluate how reduction in public health workforce initiatives may actually impact its broader goals of addressing the state's public health infrastructure, particularly in light of the ongoing 300 million. We believe that the budget solution may undercut the state's recent efforts in this regard in supporting this ongoing infrastructure.

Thank you so much. Could you speak a little bit more about how impactful these positions are, what they do, how they help during the pandemic, and to what he noted, how it could be detrimental?

So I'll talk first about the pathways program, which brings in people from a variety of backgrounds and diverse backgrounds and really serves as a pipeline. And some of the folks that could apply would include some of our contact tracers and other people who have been assisting us throughout the pandemic. We've received hundreds of applications for the pathways program, and we're able to, with the dollars that we got in current year, Fund 25 fellows that will be placed across the state.

And then Cal-EIS is for epidemiologists that would be trained across the state, and we have already allocated that money for current year. The 3.2 million. The career ladder and upskilling is meant to really help the people who are already in public health, both state and locally, to promote and get training and advancements, some of which will go out in local allocations. And right now, we got many more applicants for training and education support for the career ladder. Funding.

We've got more than 12.6 million in requests in the current year, and we'll be able to award 2.2 million of that. The microbiologist, certainly a shortage, no shortage throughout the pandemic. In terms of the need for laboratory staff, one of our hardest positions to fill are both lab microbiologists as well as laboratory directors. We have a lot of requirements for laboratory directors in the state. This funding allows about 10 lab directors to go through the program.

The lab Director training is multi year, and so this would only Fund the first year of those candidates.

The 3.2 would only Fund for one year?

Yes. Right now, because we received a 5 million reduction in current year, we have 2.2 allocated to the lab directors.

Thank you. And can you clarify on why the first one isn't included? The public health nurse certification fees?

I'll let finance comment on that one. I think that might be HKI dollars.

That is Correct. Ms. Fanelli's comment is correct. That was funding that was included in the Department of Healthcare access and Information budgets as a limited term investment.

Thank you, Senator Amra.

I'd just like to say that I don't think this is a good idea at all. Workforce is all we've been talking about, the lack of our pipeline. So it sounds like we want to close our pipeline, we want to rip the rungs off our ladder, all the things that we've worked to develop that we're just going to undo.

So I would just suggest the Department of Finance, there might be some other places that we can cut, but I don't think workforce and promoting, and we did all this because the more pathways people have, the more opportunities they have, the more training they get, the more they're happy in their jobs and they stay, they don't get burned out, they don't leave. They don't leave because they have no opportunities.

We were desperate trying to find these navigators and these contract tracers and now we have them and we want to cut them loose. That makes no sense to me at all. So I vote for reversion of the reversion.

I would say in the first hearing that we had three weeks ago, I started with opening remarks on the intent of the party here in sub three is to really protect the workforce and really look into the delays and potential cuts in this situation of the January budget. And I echo my colleague and saying that's exactly what we'll do and ensure that we protect this pipeline and we'll have further conversation on that.

For now, we're going to leave the item open and continue to issue number five on Covid-19 website information technology resources.

Thank you.

Nice to see you in person, Ms. Fanelli.

Thank you.

Good afternoon, Madam Chairwoman, Committee Members, my name is Tony Tran and I'll be covering issue five from CDPH ITSD. We are asking for continuation of funding for public health response efforts that support security and translation services to optimize and maintenance operation of the Covid-19 website. The Covid-19 website provides the ability to make improved data driven decisions by state departments and leadership.

Improve access to Covid-19 Data by Californians the ability for Californians to access public health Services funding request jet through General Fund three limited term it positions $900,000 annually for fiscal years '23,'24, '24,'25 and '25,'26 which includes licensing and operating cost.

Thank you so much. LAO, DOF, any comment?

We have no comments on this proposal.

Great. I don't have any comments or questions. Thank you so much. We're going to leave that item open and move on to issue number six, AIDS drug Assistance program estimate.

Thank you.

Thank you so much. We're going to be welcoming on Zoom Sharisse Kemp just want to make sure.

You all can hear me okay? Yes, perfect. Good afternoon, Madam Chair, Members of the Senate. My name is Sharisse Kemp and I am the branch chief who oversees the AIDS Drug Assistance program. I am glad to be before you to provide an overview of the major changes in the AIDS drug assistance program. November estimate package. Just for context, the AIDS Drug Assistance program, most commonly referred to as ADAP, provides access to life saving medications for eligible California residents living with HIV.

We also provide assistance with costs related to pre exposure prophylaxis for clients at risk for acquiring HIV and post exposure prophylaxis for clients who may have been exposed to HIV. ADAP is funded through the Federal Trust Fund and the ADAP Rebate Fund. For current year, the Budget Act of 2022 included ADAP local assistance funding for 455.1 million. The revised current year budget is 440.5 million, which is a decrease of 14.5 million when compared to the Budget Act of 2022.

This decrease is driven primarily by lower medication expenditures and premiums for insured client groups than previously estimated. Changes to ADAP's budget authority when compared to the Budget Act of 2022 include an increase of 8.1 million in federal funds and a decrease in 22.7 million in ADAP rebate funds for budget year. Proposed ADAP local assistance funding for the budget year is 440.1 million, which is a decrease of 14.9 when compared to the Budget Act of 2022.

This decrease is driven primarily by Medical expansions and lower medication expenditures and premiums for the insured client groups than previously estimated. Changes to the ADAP's budget authority when compared to the Budget Act of 2022 include an increase of 26.1 million in federal funds and a decrease of 17.5 million in adapt rebate funds. I'm happy to address any questions.

Thank you. Before questions, turn to LAO and Department of Finance for comments.

Nothing to add. Thank you.

We have no comments on this item.

I have no questions. Senator Eggman has one.

I would just be remiss if I didn't say hello to Sharisse Kemp, one of my former students. It's nice to see you doing good work.

Nice to see you, Dr. Eggman.

That's awesome. Thank you. We're going to hold that item open, and we're going to move on to issue number seven. California Immunization Registry as related to AB 1797.

Hi, good afternoon. My name is Rob Schecter from California Department of Public Health Immunization Branch, and thank you for the time. Today, California has long standing immunization registry, a database of both childhood and adult lifespan immunization records that has been largely voluntary over the last decades. In its existence, a few parties are required to report by law, including pharmacies in California. And from a federal requirement, Covid-19 Vaccine doses are also required to go in each state's immunization registry.

California's immunization registry, or care as that would imply, is similar to immunization information systems around the country. Last year, Assembly Bill 1797 was passed and chaptered, which, as one provision, requires immunizers in California, whether immunizing children or adults, to report doses into the immunization registry. Because up until now, it's been largely voluntary. There are still thousands of providers in California who are not yet on the system.

And so the Fund request related to the Bill is for additional staff at CDPH to support to onboard these providers now subject to the requirements of AB 1797. So a combination of some part time and full time staff over the next years to build up this important information system. Some of the value of which has been evident during the COVID pandemic.

Some of you may have seen or heard of the digital vaccine record in which individuals online could get rapid proof of their Covid vaccines for occupational or to attend events or for various purposes. And that was tapping into the data within the database and example of what more can be accomplished as more and more data enters the system to add to the hundreds of millions of records that are already there. Thank you for your attention and happy to answer any questions.

Thank you, Robert. Department of Finance. Any comment?

Sorry, nothing to add.

LAO, any comment?