Assembly Standing Committee on Health

Building the workforce of community health workers, promotoras, and representatives and financing the services they provide in a way that is meaningful and attentive are promising strategies to promote health equity and personcentered, culturally competent care. By leveraging their deep understanding of and connection to their communities, CHWs, promotoras, and representatives can help people improve their health and access to care.

Evidence demonstrates that CHWs broadly use to be able to refer to all three categories can improve health outcomes and health equity in a variety of settings with differing populations and with specific diseases and conditions. California recently enacted two major initiatives in this space. First, we added CHW services as a medical benefit starting in 2022, and we've deployed CHWs in specific roles under CalAIM.

Second, we've approved a very large, multiyear workforce initiative to promote CHWs promotoras and representative workforces $281.4 million over three years to recruit, train and certify 25,000 new CHWs by 2025. Both initiatives are still in early stages of implementation. There is certainly excitement about these investments and promising developments, but we have also heard about various barriers to expand our CHW, promotora, and representative workforce and services generically.

I also want to be clear that we are embarking on a path that has been very well laid in terms of a foundation. These state initiatives are building on a foundation of very difficult, underpaid, and often thankless work that community health workers, promotoras, and community health representatives have done for decades. They have been on the ground in communities throughout the state pushing for health equity and justice, taking care of the people, and they are experts in how to do this work.

We are along for the ride as a state. We are grateful for their presence and work. We honor them and lift up their legacy and their continued work as we move forward together because we can build on the incredibly strong foundation that they have offered us in a way that is at scale and is ensured to be able to support every Californian. This hearing aims to provide background on CHWs, promotoras, and representatives.

And recent state efforts discussing both the bright spots and challenges in implementation of state initiatives and the broader deployment of CHWs. And challenges involve several things. They involve our stakeholders to think deeply about how we can get more done and be more efficient, as well as being culturally connected in very meaningful ways at the heart of what we actually know is helpful when we are talking about community health work.

As well, we want to ensure that every stakeholder can do their work within their unique role to help the state realize the transformative potential of community health workers, promotoras, and to improve health and health equity in California. I will now turn comments over to the committee. If there are any opening comments, I will say that we have two very robust panels to be present. We have wonderful members of our community here to present information to us.

So we are going to try to focus on ending this hearing by 4:00. That is our target. So forgive me if I am gleefully moving us on just to make sure that we can make sure to hear from everybody present and then also end with public comment. With that, I will turn it over to Dr. Arambula. Seeing no further comments, and we'll wait for Dr. Weber to join us. So thank you. With that, we will ask the first panel to come forward.

As they're moving up, we have Carlina Hansen, program officer at the California Health Care Foundation, Mayra Alvarez, president of the Children's Partnership, Dr. Seciah Aquino, executive director of the Latino Coalition for Healthy California, and we had Dr. Mark Ghaly, secretary, California Health and Human Services Agency, walking into the room right now. Right on cue, Dr. Ghaly. With that, we will move forward with Ms. Hansen.

Carlina Hansen, I'm a senior program officer with the Health Care Foundation. Thank you so much for having me today. Community health workers, promotoras, and representatives, also known as CHWPRs, are trusted local leaders in our California communities who offer a wide array of health and human services and have been doing so since the 1970s and some would say long before then. Promotoras de la salud largely work in Latino, Latinx, and Spanish-speaking communities, whereas community health representatives center their work in American Indian communities.

CHWPRs are already playing an important role in the lives of your constituents. They are people who have the unique perspective of having been on both sides of the systems and institutions that make up the safety net in your communities. In a healthcare context, as Chair Bonta said, they provide a wide array of services, including culturally appropriate health promotion and education, assistance in accessing medical and social services, care coordination, patient advocacy, and so much more.

Numerous studies have shown that this workforce can help people improve their health, accessing primary care, managing their diabetes or cardiovascular disease, controlling hypertension, and obtaining necessary cancer screenings. I have personally seen the power of this workforce. Prior to my time at CHCF, I was the executive director of a health center in San Francisco where we trained upwards of 50 CHWs per year for over 20 years.

Our CHWs supported people in need of sexual and reproductive health care and did outreach with people experiencing homelessness and people living in public housing. The vast majority have continued their work in the healthcare safety net, and like many CHWPRs, they have a lifelong dedication and commitment to serving the community. We know from data and from community experiences community experience that health systems that are designed to support Californians have work to do to dismantle systemic racism.

CHWPRs are one important part of the solution. That is why CHCF has prioritized investing in and advancing the CHWPR workforce in California. CHWPRs are racially, ethnically, and linguistically diverse, and they often have other intersecting identities that they share with those they serve, having had an experience of homelessness or incarceration, or having a shared identity around gender expression or socioeconomic status. This is especially important because the majority of our health workforce in California does not match the demographics of the state, let alone of Medi-Cal.

For example, approximately 7% of California's physicians are Latino, whereas Latinos make up approximately 40% of the state's population. Additionally, health systems and managed care plans in California are increasingly being called upon to proactively reach into communities to meet people where they are and coordinate their care both in and outside of the walls of the healthcare environment. The push to greater connection to community acknowledges that people's lives are complex and that it is very challenging to navigate the health and social service safety net.

CHWPRs are seen as an important part of this effort. Their work often happens in the community, at health fairs, in churches, in homeless encampments, and community centers. They not only build trust, but as one promotoras said recently, they play an important role in repairing trust. As you know, we are in a time of acute health workforce shortages. 11 million Californians, that is more than a quarter of our state's population, live in a federally designated primary care health professional shortage area.

This makes it all the more important that health systems rely on a diverse, interprofessional team who are working to the top of their scope and capabilities to ensure that people's health and social service needs are adequately met. CHWPR work involves taking the time to understand people's health needs and barriers and to act as advocates. That is, not time that is otherwise spent. In the course of a 15-minute healthcare visit.

But it is time that evidence tells us can have an impact on people's health outcomes and well being. Although there has always been a demand for CHWPRs, the COVID-19 pandemic created additional demand. They were on the front lines already embedded in their communities, responding almost immediately to the need that they were seeing. Their work called attention to the instrumental role that they play in reaching communities most impacted by health disparities.

A recent survey conducted by UCSF Health Force Center tells us that CHWPRs working in clinics and hospitals earn anywhere from $16 to $30 per hour, depending on their experience and where they're employed. The same survey tells us that both hospitals and clinics want to hire more CHWPRs. Hospitals said that they would hire approximately 10 times the number of CHWPRs than they currently have planned. Health centers would hire almost three times more.

Unfortunately, they also told us that they planned to hire far less than this due in large part to the constraints associated with the financing and sustainability of these roles, a challenge that was cited by both hospitals and health centers. The Bureau of Labor Statistics tells us that there are 6700 CHWs in California, with a projected growth to 7900 by 2030. That's an 18% increase, which is much faster than average due to the variety of job titles and labor classification codes for CHWs.

It is likely that this is a significant undercount. Research also tells us that demand outweighs supply for this workforce. In order to advance, CHWPRs need additional support, including thriving wages, good training, opportunities for advancement and recognition, supportive supervision, and good workplace integration. In addition to the value of the services they provide, this is an emerging job opportunity for your constituents. UCSF Health Force identified approximately 25 training programs for CHWPRs in California, which are predominantly clustered around Los Angeles and the San Francisco Bay Area.

Several of those programs offer training in other parts of the state, including the Central Valley. However, there are many parts of the state, including the rural North, who have shortages of training programs and CHWPR workforce. The past several years have shown a number of exciting changes which Chair Bonta enumerated, which include financing to scale the workforce as part of the state budget, the opportunity to be reimbursed through the new CHW benefit, and opportunities in CalAIM.

Additionally, there are new provider codes and reimbursement for CHWPRs in Medicare, which opens the door for them to provide additional services for seniors and people with disabilities. Several speakers today will touch on those investments. CHCF is currently supporting CHWPR expansion in four regions in California, San Diego, Alameda, Central Coast, and Riverside, San Bernardino, and Orange County. These regions are helping us to understand what it takes to help this workforce thrive and what it means to implement impactful, sustainable programs.

You will hear from several of them today. My hope is that you take away these four things from the conversation today. CHWPRs are trusted health workers who are already working to advance health equity in California. They are representative of the state's diverse population and provide culturally and linguistically concordant care. They augment the capacity of the healthcare team in a time of acute health workforce shortages and that demand outweighs supply and ongoing support and investment are needed to advance this important workforce in California. Thank you so much for your time today.

Thank you so much. We will move on now to Mayra Alvarez, the president of the Children's Partnership.

Good afternoon Chair Bonta and esteemed members of the committee. My name is Mayra Alvarez and I serve as president of the Children's Partnership, a statewide advocacy organization focused on advancing child health equity through research, policy, and community engagement. We believe that all children, regardless of race, ethnicity, or place of birth, should have the resources and opportunities they need to grow up healthy and thrive. A fundamental component of that work is building a healthcare system that responds to the needs of California's diverse children and families.

Aligned with this work, we are proud to be a part of the Steering Committee of California's Community Health Workers, Promotoras, and Representatives Coalition. My comments today seek to reflect the perspective of the coalition and further information will be shared by individual organizations throughout today's hearing. Building on Carlina's comments. CHWPRs are a long-standing model of care in California, the country, and across the globe in response to systems of care that were not meeting the needs of diverse communities.

Systemic racism and a culture of white supremacy have created conditions within our country, state, and communities, including our healthcare system, that actively threaten the physical and mental well-being of people of color, impede their access to healthcare, and make the healthcare they do access ineffective and potentially harmful.

There are more than 60 years of formal research documenting the effectiveness of CHWPR interventions, but it is clear that this profession emerged in direct response to the failure of systems and structures centuries ago, combating generations of discrimination, racism, and deeply entrenched systemic inequities that have hindered opportunities for health and well being for marginalized communities. What we know is that communities found a way.

Communities recognize the power that exists in knowing you have a support network and families and neighbors that will do anything to help communities create a culture that nurtures you. Not one of us made it to where we are alone, and CHWPRs embody this belief. For centuries, communities themselves implemented solutions out of necessity. Communities created those networks of care. They trained community health workers. They integrated care into the community because the traditional healthcare system was not meeting their needs or worse, mistreating them.

It is within this context that CHWPRs and more are a community-led antiracist solution in healthcare delivery for children and adults from prenatal development to late adulthood. Antiracist strategies are conscious and deliberate efforts that address and eradicate historical and present marginalization and inequality, impacting BIPOC communities. A community health workforce is an antiracist strategy because it shifts power through partnerships in which people who directly experience the conditions that cause inequities have leadership roles and avenues to share their perspectives within healthcare organizations.

Shifting power supports a health workforce that better reflects the communities served while also providing employment opportunities in those communities that stabilize families. In doing so, a bridge is created between families and their communities to the health systems serving them that can support institutional changes in those systems to be more culturally, linguistically, and ethnically responsive and diverse. Characterized by Servicio De Corazon, or service from the heart, as Vision y Compromiso shares, CHWPRs have served California communities for decades.

Promotora-centered community interventions that embraced a popular education approach spread throughout the 1990s, including El Sol Neighborhood Educational Center and Latino health access, and shortly thereafter, we saw community health workers be a part of community health centers and their work to connect with patients in statewide networks such as Vision y Compromiso, and others that ascended in the early 2000s.

For decades, Californians have benefited from the trust, expertise, connection, respect, and love of CHWPRs, and it is local, state, and federal agencies that have benefited as well, leveraging the ability of CHWPRs to engage with families, their cultural expertise, their connection to community, ability to cultivate relationships, and their flexibility and responsiveness, all assets not emphasized in traditional medical training. With these incredible strengths, CHWPRs have been deployed in California through a variety of mechanisms. They support the physical, mental, and social-emotional health of children, families, and communities.

Our health systems, hospitals, clinics, public health departments rely on CHWPRs to improve the utilization of preventive services, medication adherence, chronic disease management, and care for certain health conditions. They provide effective asthma self-management and environmental education, bridging the gap between patients and providers, offering social services such as interpretation and referrals, and perform care coordination. They support the adults that children rely on building self-efficacy, confidence, and health literacy. They help people navigate complex government systems, including education, healthcare, and social services.

They are advocates for social justice who have a unique ability to improve the conditions in which we all live, learn, grow, and play. Most recently, we can look to the pandemic as evidence of the critical role of CHWPRs as they emerged on the front line early on as essential workers. While in-person visits were restricted, CHWPRs were able to pivot quickly and connect with families via video, conference, phone, text, and email.

In many communities, it was CHWPRs who took charge of contact tracing and follow-ups, particularly for families without working telephones. Given their trust, their connection, they quickly identified those most marginalized, reaching those who were deemed unreachable, and ensured that resources made it to the families who needed them most. In Los Angeles, the United American Indian involvement CHWPRs quickly mobilized to deliver personal protective equipment, food, take home tests, and assisted with telehealth appointments, promoting vaccinations, and providing social and emotional support to the city's urban Indian population.

It is why the Federal Government allocated over $3 billion to aid community based organizations and public health departments in hiring CHWPRs through the American Rescue Plan to leverage that very expertise. Because throughout these various efforts, CHWPRs are structured differently, often in direct response to what communities specifically need. They have a long history of working in community, both within healthcare as well as outside of healthcare, and are having more opportunity to be integrated into traditional settings because of opportunities like the CHW benefit.

However, as this work to further integrate CHWPRs continues, there is a need to sustain the existing workforce and not just expand on what we know is not working. CHWPRs, as Carlina mentioned, often work in hourly positions that pay less than a living wage. They have drastically lower salaries despite their many contributions. There's also a high number of volunteer positions. Boosting the wages of CHWPRs can help them overcome challenges with transportation.

Again, much of this economic injustice is rooted in systemic racism, as shared by our partner, El Sol in their recent report, many organizations have experienced the challenges of not having the organizational readiness or support systems in place to respond to CHWPRs. Achieving health equity for our children and families requires our healthcare system to uncover, acknowledge, and address systemic barriers through community-focused efforts that center and meaningfully engage people who come from communities that have been historically oppressed.

We see this happening through Pomodoras, through community health representatives, doulas, peer counselors. There is a wide variety of community health workers making a difference. The State of California is in the midst of a transformation of our healthcare system with multiple efforts to strengthen Medi-Cal and reform delivery. As that work continues, let us limit or eliminate the harms upon our communities and prioritize solutions that challenge the status quo.

Bring care to the community, initiatives that refuse healthcare to be transactional, and finally, a validation of the brilliance of community leaders, recognizing that those closest to the problem are closest to the solution, as the quote goes. CHWPRs are born, not made. A call to action to stay true to the spirit of the model while opening doors to the services that we know are so essential. There's no better time than now. Thank you for the opportunity.

Thank you. And I just want to welcome Mr. Reginald Jones-Sawyer III, our Health Committee member, and our majority leader, Ms. Aguiar-Curry, who has been leading us in this space in the Legislature for quite a while. So thank you for participating. And with that, we will move on to Dr. Aquino, executive director of the Latino Coalition for Healthy California.

Thank you so much, Chairwoman Bonta and esteemed members of the committee. It is a joy to join you all today. I am Dr. Seciah Aquino and I serve as executive director at the Latino Coalition for Healthy California. At LCHC, we are committed to advancing and protecting Latine and Mesoamerican indigenous health through policy change. We pride ourselves in translating community solutions into equitable policy and lasting systemic change. Our policy work is rooted in community and led by our statewide promotora network.

From our annual listening tour to our Pasa La Vos community Platicas to the advocacy of our legislative priorities, promotoras lead the way. I actually started my journey in public health as a promotora, so this topic is near and dear to my heart. Now, there is no denying that the role of the promotora CHWPR is not only widely accepted, but loved and respected. Unfortunately, the role continues to be treated as a contracted position.

The reality of a contractor role is that jobs are time-limited and lack employee benefits such as health insurance. The work we're currently doing across the state to increase access to CHWPRs, including our DHCs and HCAI efforts, helps us increase access to the role and thus moves the needle forward to equality. And that's great. Let's keep doing more of that. But it is time now to envision the future.

We must begin to adapt additional strategies that will help us advance from equality to equity and eventually justice. The majority of CHWPR roles are held by women and women of color at that. Women of color and specifically Latinas, have been historically disenfranchised, and that has had a compounding effect in increasing health and socioeconomic disparities. These disparities can only be addressed by intentionally investing and increasing access to opportunities that can race us back to parity.

One of those additional strategies is to transform the promotora role from contractor roles to full-time positions, full-time positions with benefits, salaries, and career growth opportunities. From a systems perspective, integrating the role into existing systems, such as our state agencies and departments is the most sustainable way to grow and develop the role. A comprehensive integration of promotoras in state leadership and management positions will facilitate successful monitoring and evaluation of the work.

Incorporating promotora values and strategies into all levels of our existing systems will ensure that this is not perceived as an additional step to outsource, but rather as an integral component of our state's strategic framework. This is a strategy that will not only transform our workforce but will actively invest in Latine communities. Latinas are powerful economic force, and when we choose to invest in Latinas, we successfully create an economic ripple effect that will in turn protect families, communities, and full networks across the state. Economic prosperity and health are intricately linked. Therefore, hiring promotoras for full-time positions is not only an anti-poverty strategy, but a public health one that will in turn improve the health of our state. Thank you.

Thank you so much, Dr. Aquino. We'll move on to Dr. Ghaly, our secretary of California Health and Human Services.

Good afternoon. Thank you, Chair Bonta and other members of the committee for inviting me today, and thank you for the fellow panelists. I really stand on their words. I think that the shaping of this conversation around how vital our move into CHWPR roles is really critical. As all of you know, you've been around California healthcare long enough.

We have a real need to reinvent the system that is delivering care to 40 million people, and that reinvention has a lot to do with the workforce that we're asking to do the work. And similar to some of the stories you heard, my own experience working with community health workers in my first job after residency in the Bayview Hunters Point community of San Francisco really built my belief that we have a lot of benefit to gain from really exploring the richness of what I call this community professional role. I know I walk around as a health professional, a trained MD, but this role of community professional is real, and I appreciated the concept of bridging.

While in medical school, I realized early that medicine is 10% diagnosis, 90% plan, and in so many settings we miss how hard it is to come up with the plan, and I have in my work as a pediatrician, as an adolescent provider, depended on community health workers, in particular in the Bayview Hunters Point community later in south Los Angeles, to really translate and create robust plans that made a difference and move the needle on health.

And those individuals that I had the privilege of working with in a team-based model were exactly the special sauce, the secret ingredient that really turned what might have been a set of ongoing appointments without a lot of meaningful movement, whether it's a diabetes indicator or an asthma indicator or counseling around violence, into something that was actually meaningful and changed the lives of the people that I had the privilege of serving. We did this in a county health system.

We were able to identify and build community health worker roles. Not every county gave that opportunity but built it as part of the system. And I think the prior panelists give hope that we're able to do that in an even bigger way. To hear, frankly, I like that we're growing by 18% over the next many years, but the small number, given our population of currently identified and employed promotoras, community health workers, and health representatives, is too low for a state this size.

And I'm proud of the work that we've done over the past couple of years. Whether it's our work at HCAI on building up the workforce and identifying the elements of a certification program, or the really important work on building a community health worker benefit for Medicaid, these are important steps, but not enough. We need to continue to build those. So this notion that these are well respected, important jobs, that they're professional roles in our both community health system and health services system is key.

And your role in helping lead the way, working hand in hand with our departments in health and human services, the administration at large, to really advance this notion that we can do more and do better in this space, I think is very critical. We know that this is a new journey for us in state government to figure out how to really tap into the expertise of our communities, those who are doing the work to create roles and responsibilities that fit the challenge.

I don't see a road forward if we continue to depend on our current stable of health professionals to get this work done in the way that lifts up not just the health care outcomes, but these important shifts in power that communities that too long have been overlooked suffer from today.

And so as we continue to see a road forward and we work with the dozens, hundreds, frankly of partners and community to figure out the best way to do this as we push ourselves to explore how to make the jobs meaningful, not only from their role and impact, because that has been there all the time, but as a true springboard to life-sustaining jobs and roles that are very deeply respected, not just outside of the healthcare system, but within it, and how they become pillars of our healthcare delivery teams.

I think it's important that we continue to have these conversations. No longer should we just look to the halls of medical schools and nursing schools, but to the communities, the backyards, the storefronts for the people who can really move the needle on health. And we see that in the evidence that was presented by prior panelists and even in those wonky return on investment articles that come out of academia that show for every dollar invested in a promotora, community health worker, or representative, we get at least two and a half dollars back in return.

So as both, somebody who benefited as a direct physician in some of our most complex communities in California, as somebody who's had the privilege of sitting in this role as health secretary and seeing the challenges in front of this state, I can't see how we get to the sort of outcomes I know all of you expect us to get to without not just a serious conversation here, but our ongoing investment in these programs and making sure that they don't just live grant to grant, budget cycle to budget cycle, but that they're hardwired into the way we expect to deliver care into the future. Thank you.

Thank you, Dr. Ghaly. I will open it up for questions from the committee at this point. Dr. Arambula.

Thank you, Madam Chair. First, I'm going to give my appreciation to the staff for the write-up today. I thought it was very well done. I thought the analogy about building a foundation is the appropriate analogy for us as a state. We have done a lot of the hard work and legwork to get us to this point, but we do need to make sure that we're meeting the need.

And so I really want to talk about that if I can, because at the moment, it doesn't seem that we've been training enough CHWPRs and that we have training deserts all over our state. I couldn't help but notice on your map, Carlina Hansen, that there was only Bakersfield Community College in the Central Valley up to Sacramento.

Well, we have 5 million people in the 5 hours between those places and have to believe there are more opportunities for us to find training that I question whether we've looked towards adult education or if we need a community college degree, is there an opportunity for us to meet ESL adults where they're at and give them that bridge to employment that was mentioned here. What would be required for us to do just that?

Wonderful question, and you're right, we do have a lot of training deserts in the State of California and a great amount of need that I think the panel has spoken to. We are seeing some expansion since the release of that report, I think driven in part by demand and exactly in the places that you're mentioning in community colleges.

We also have wonderful representation here today from a number of organizations who have years and years of experience training community health workers, promotoras, and community health representatives that are organizations that are very connected to their communities and not unlike the workforce. I think it's important that we support and shore up those organizations who have been doing this for so long and who know the needs of their communities well and know the workforce well. Vision y Compromiso, El Sol, et cetera. Those are wonderful organizations. But I do think that there's a complement of expertise that can be provided and training that can be provided by our community college system, and I do think that that's happening and expanding.

Dr. Ghaly.

Yeah. I'll add, I think over the last couple of budget cycles, we've had investments through HCAI in building up the infrastructure. I think there is this really important complement of building up our existing, very experienced groups within communities. You've heard their names, there's others, but also looking to see what's the role of our formal, maybe community college system, other parts of our systems.

I do believe as we make the CHW benefit within Medicaid more robust, hopefully see increased uptake with time, obviously start slow, but that will drive some of the opportunity there. I mean, you know this. You all know this very well. You provide the resources, you can start to build some of the program. You build some of the program without the resource, it often falls flat. So I do think that the next many months and years are going to be a testimony to building that capacity up.

And hopefully in a year or two, you see a very different map where the training opportunities are because there are real life pipelines into jobs that through our managed care systems, through our health systems, through our public health systems, we're actually lifting them up and making them available.

And I do want to uplift the work of the CBOs, who are the trusted messengers who have been in community, who have long-established trust. I want to uplift the comment about needing to repair the trust that for so many of our communities was earned and so I look forward to how we can support those groups who have been on the ground. Part of your answer, though, Dr. Ghaly, was about reimbursement.

And so I'll then focus, if I can, on our FQHCs explicitly and their inability to contract with CHWs at the moment because of PPS versus fee for service, and would highlight in the agenda that there were three states that are finding ways to work around this. I believe it was Michigan, Kansas, and Rhode Island who instead allow us to do that fee for service outside of the PPs rate. I will say within California there are examples, precedents for this.

I'd uplift our CalAIM, ECM, as well as our supportive services as examples where we've already done this to question can we look towards creating a workaround or can we directly fund those CBOs to make sure that they're being reimbursed for the community health workers who will be seeing people within our FQHCs?

As you know, the PPS system has some rigidity to it and doesn't allow certain things to happen. But yes, we have done workarounds. We could continue to explore that and see how we work with our FQHC partners, our community partners, to uplift this. I do believe that as the benefit, the CHW benefit in Medicaid becomes a little bit more, not just robust, but experienced, that this is a very natural place to go.

It's hard for me to close my eyes and imagine the health delivery system in California without FQHCs benefiting from the important work that CHWPRs could bring. So figuring that piece out, I think, is part of the puzzle moving forward and reimbursement. Frankly, the fact that we're today talking about reimbursement, and we're not just talking about what's the next big grant program for CHWPRs, I think is a big leap forward, and now we have to execute on some of the important questions you're raising.

I'm going to move on to our majority leader.

Good afternoon. Thank you very much. And I want to also thank the audience that's here. We all know what an important topic this is. My main thing is I really want to make sure we have ongoing investment because this is such an important program, the programs, and to see the momentum going. And I'm someone that doesn't like to see anything left at the table, and I'm afraid if we don't keep the momentum, then we take a couple of steps backwards.

So I love the words that you use this afternoon. Trusted, diverse, augment the capacity of the healthcare team, and remember the demand outweighs supply. We need to continue to work with our people to make sure we get the health access that we need in all over the state, but primarily in our rural areas. I've seen the work you've done. I've seen how it's changed people's lives.

And so, unfortunately, as we've commented a couple of times, when COVID came, it hit us and we really tapped into our healthcare workers. And so I want to just thank you all today for coming, but look forward to the rest of the conversation today. Thank you.

Thank you. I'll move on to Mr. Jones-Sawyer.

Okay, thank you. I just want to just quickly make sure that I commend Dr. Ghaly and others that during the pandemic-- I represent South Central Los Angeles. As you know, we don't have hospitals, like zero, none. And when the pandemic hit, all resources were going to hospitals. And when my colleagues and I brought to the state's attention that there weren't vaccines going to South Central Los Angeles, there weren't testing going to South Central Los Angeles.

First, people were saying they need to go to their local hospitals and said, well, some of that's not practical, but also to seek CHWs. They were the trusted messengers. There were people who were undocumented. They were not going to a hospital, but they would go to a clinic. I have a plethora of clinics in South Los Angeles, South Central Los Angeles. And people were going to them every day, every way, seven days a week.

And that was their health care professional, and they trusted the CHWs and to provide that. And so once we got funding for clinics, which wasn't provided at first, once we got funding, I think our numbers started to go down as the number of people who were suffering from COVID-19 and it was because we recognized where there was a hole or deficiency.

We were making these assumptions that all people could go to Kaiser and Cedars-Sinai and all of these wonderful medical centers when that was not the fact. And I want to thank the state for recognizing that and be able to provide that.

Because at the end of the day, when it comes to people with good communication skills, when it comes to people who have interpersonal skills, dealing with people, service coordination, the capacity to building skills, outreach skills, because they outreach to the community every day anyway, professional skills and contact evaluation and research skills. But most important, their knowledge base.

They knew the people in my district, and they knew what it took to get them the kind of medical care that they needed so they could protect themselves and their family, there were people who wouldn't go out of their home and wouldn't let anybody come into their home, but they let a CHW in. And so I'm glad that we recognized that, and we recognized that early.

Thank you. I'll ask a couple of questions, and we need to wind down on this portion of our hearing today, and I'll turn the floor over to my colleague, Dr. Weber.

I just wanted to, one, acknowledge and really appreciate Ms. Alvarez for putting the context of what the intention of having community health workers, promotoras and representatives are, which is to really be able to combat the deeply rooted systemic inequities that have existed for generations, creating the kind of disparities that we have and really being able to lift up cultural practice that has made a big difference for people, both linguistically and when we're kind of connected with experience to individuals and communities for their care.

And part of what I see is happening, and I'll just kind of offer an opportunity for all of you to make comment on this, is that we have this wonderful opportunity to be cognizant of the systemic inequities. But we're doing that within the context of state initiatives that were, quite frankly, organic agencies or kind of culture, whatever it might be, that is really unfortunately, grounded in systemic inequities.

So whether it's reimbursements, whether it's contracting versus promoting full time workers positions, whether it's ensuring that we have an opportunity to fully address and embrace this kind of integration, we're going to run into incredible, I will say nicely, stumbling blocks. Reality is for people on the front lines, incredible barriers.

So my question really for all four of you to be able to address is what are the things that we need to do from a state level, given your experience, to really be able to be focused in addressing some of the systemic barriers that are just inherent to our system. And we'll go this way and end with Dr. Ghaly.

Thank you. Well, first of all, thank you so much for stating that. As we think about the lasting role and the impact of the role, right, we do need to systematize the role. But to your point, when we systematize, we're entering a system that already wasn't created for us or by us. And so we need to be extremely intentional to those barriers to entry. So something that advocates talk about in our work is making sure that we are thinking about language access, immigration status and barriers to education.

So creating more flexible guidelines to make sure that community members who might not have the level of income or opportunity to get higher education to invest in a certificate program are able to enter that workforce. And for a lot of our lower income community members, that makes a huge difference. And so being very intentional to include that and transform the system that's currently leaving a lot of us out.

Thank you, Chair Bonta, for that question. And building on my colleagues'comments, I think it's important to consider the role of consistent community voice and input in the process. Already with implementation of the CHW benefit as well as the training opportunities that HKI worked to move forward, there's been challenges because CHW/P/Rs have not been at the table in a formal way, and that's for any number of reasons. The intention may have been there, but the space was not created.

There was no formal structure for that input and communication. I can give you a comparison. The doula benefit that we are excited to see move forward had a formal stakeholder workgroup that showed meaningful progress in the last couple of years and implementation of that benefit. It's still the story to be told as far as implementation and its success, but it had a formal work group. CHW/P/Rs do not have that. And thankfully, the Department has opened many lines of communication and created many meetings.

But where is the opportunity to have that formal connection to the experts? These are the folks that know how to get things done. They can share what are the challenges at the local level. The intention is there. How can we make sure that the impact is successful? And what we need to do is really center the experiences of these people and give them the formality, the validation that they are experts, they are leaders, and that they should be treated as such in our system.

Thank you so much for the question, Chair Bonta. So I think one extremely important thing is that we need to be cautious not to create poverty jobs. We've talked about how important these roles are, and we need to think about what is driving the wages that support this workforce. As Seciah said, these are predominantly Latinas who are from the community and rooted in the community.

And so we need to make sure that they and their families can thrive in their health and well being while they are supporting others and thriving. I would say also so much of our attention has focused on sort of the support of the CBOs and entities that are supporting and training and hiring CHWs, and that definitely needs to continue.

I think it's also important that we support our managed care plans, our healthcare systems and others in truly understanding what this workforce is about so that they can be supported well in their jobs and again, thrive in their lives, but also in their roles. And then I would sort of echo your comments about investment in training. I think we need to continue to invest in training programs if we truly want to support this workforce. It's not just about initial training.

It's about ongoing training that is affordable, accessible, and that is going to help them advance in their roles. Thank you.

I think this is the critical question, can we actually do this in a way that is authentic and lifts up the voice of those who are the experts? And I will say that a few months ago we were clearly not on that road to doing it. I think the comments of Ms. Alvarez were spot on. Despite intent to get there, we weren't.

Since that point, I think through some insistence in working within our own government structures and working with the community, we've created some more space to do this. It's a start. It has to continue. It can't sort of rest when the first task is completed. I think it really does have to be hand in hand work.

And one of the things I'm really proud of both HCAI and DHCS over the last year or two is really creating the muscle memory of how to do this kind of engagement on a number of issues. We hear a little bit about the process around the doula benefit, bringing a similar approach where it's a lot of listening, we're inviting the right people into the room and a lot of people into the room.

So I hope that that will be one way to protect against us turning this into a sort of bureaucratic benefit that doesn't advance the true benefits of the role, which I think the other panelists highlighted so vividly and accurately. So I would say that we need to be held accountable to do that well. And there's ways to do that that we know, and there's other ways that I hope you'll push us on in the future, but I think that's really what's going to matter.

And yes, it has to do with how do we structure this entire benefit and program in a thoughtful way. But ultimately, are we moving the needle on health through the roles and responsibilities of CHW/P/Rs in the way that we would expect the healthcare delivery system and our public health systems to do in a high quality way?

Well, thank you, Dr. Ghaly. Thank you to all of our panelists for your insights. We are going to move now to our second panel. Really appreciate your time and commitment to helping to raise this issue. And with that, while our second panel is moving up, I'm going to pass the mic over to my colleague, Dr. Weber.

Well, thank you, Chair Bonta. And I do apologize to everyone for being a little tardy and missing the first panel.

I had a few bills of my own that I had to present in another Committee. And as the second panel is coming up, I just kind of want to echo something that Dr. Ghaly just said, which know with this program, with the creation, with the design, we want to make sure that we are moving the needle with a lot of the health disparities that we're seeing here, unfortunately, here in California.

And so as these programs are designed, really want people to keep that in mind that we want these individuals to be able to do the best that they can to improve the disparities. And in order to do that, we have to look to see where the disparities occur, are occurring and ensure that we are getting community workers from those communities to actually be able to go and improve maternal and morbidity outcomes, improve our rates of diabetes and stroke and things like that.

And so not just kind of looking at who lives in California, but also looking to see who is the sickest and what gaps we need to close as far as our healthcare disparities when we're looking at this program. So our next panel is on stakeholders perspective, successes, challenges and opportunities. And we will hear from the following speakers.

We will hear from Maria Lemus, the Executive Director of Visión y Compromiso, Katie Andrew, Director of Government Affairs, Quality & Behavioral Health, Local Health Plans of California, Alex Fajardo, Executive Director for El Sol Neighborhood Educational Center, Dantia Hudson, Program Director, Alameda County Health Coach Program from Alameda County Health Care Service Agency, Dr. Thu Quach, President, Asian Health Services on behalf of California Primary Care Association, Dr. Mark LeBeau, Chief Executive Officer for California Rural Indian Health Board and Andrea Mackey, Senior Policy Manager and Lead CHW/P/R Coalition, California Pan-Ethnic Health Network.

And we will begin with Maria Lemus. Thank you.

Thank you. Thank you very much, Madam Chair. It's a pleasure to be here and to present before all of you. My name is Maria Lemus, and I'm founding Executive Director of Visión y Compromiso. I'm a promotora. My grandmother was a promotora. My mother was a promotora. My Tia, you name it. The women in my family were promotoras. As many of you may have a promotor, the person with a spirito servicio in your family, it's not a new concept.

It exists in every community, whether we're African American, we're European, we're Latinos, whatever. There is somebody in your family who has that spirit of service, who's always helping. 24 years ago, we came together at a conference where I met other promotoras. Before then, we were all scattered. We were known as CHOWs. We were community health outreach workers. We were known under different titles. But 24 years ago, we had the opportunity to come together, and we found each other. We found like-minded, mostly women.

And those women, about 100 of us, led by five of us, is who formed the network of promotoras and community health workers. La red de promotoras y trabajadores comunitarios. We started to meet five women, turned into 100, turned into 200, and now we're thousands across California and across the nation in 15 states. It's not a miracle that this exists. We found a space where we could come together, we could learn, share and build community. It is at the request of those promotoras that the Vision y Compromiso was formed.

And it is the request of those promotoras that we continue to train, provide leadership and advocacy, inform and educate our communities. Those principles 24 years ago still holds true. We're the convener of the national network of promotoras that includes 15 states. Our coalition, la Alianza, of community based organizations who have been around longer than I have, than Vision y Compromiso has, 24 years. There are many organizations have been doing this work much longer and go unrecognized.

They're small and medium sized organizations across California and across the United States and they have a long history of training, hiring and supporting promotoras. In 2009, Vision y Compromiso was acknowledged by the California Assembly with a resolution for its partnership with the Promotor Community Health Worker workforce for its unique understanding of community issues and is positioned to address the ongoing, ever changing social and environmental determinants of health and community well being. That was a benchmark for us in 2009.

It also established October as promotor month which we celebrate each year. Today, promotoras and community health workers and community leaders are recognized as essential workers. Promotoras are not stakeholders or essential workers. We are the core of the conversation. We are the bridge. We are the community solution. We have shown that year after year after year and probably highlighted during the COVID pandemic, as was referred to earlier. Who would go into the fields? Who would go into our neighborhoods?

It was promotoras and community health workers without a care for their own safety. They were there even though they couldn't get vaccinated because they weren't recognized as community health workers. Promotoras affiliated with CBOs had a difficult time, yet they were there. They were the first ones and the last ones. First one to be there and last ones to leave. Changing today we speak of an opportunity that will impact many communities and agencies.

Changing our Medi-Cal program is a big lift and we applaud the state for intentionally bringing the voices of community based organizations and individuals to shape this work. On behalf of thousands of promotoras in California and the partners of a la Alianza serving our predominantly immigrant residents, I would like to share three reflections and one recommendation. Engaging the community in statewide policy decisions is complicated. It takes time. If we want these policies to be effective, we have to involve those who are most impacted.

Doing so with openness and cultural humility brings trust and will lead to better working relationships in the long run. Look to the experts. Community based organizations have been doing this work 30 years and more. Look to the experts. Business as usual won't work. If we want our care system to change, we have to change how we approach our work. The Medi-Cal program is investing in promotoras because it's a system that works. The Medi-Cal program should change to meet community needs, not the other way around.

We talked earlier. It was mentioned about how the system has been around for a long time. As a former state worker and a recovering state worker, I think that it takes time to change. It takes time to move your perspective that you're the one who knows what is best for the community. It took time for me to change my perspective and to be humbled enough to know that I don't know anything. In the community framework, the state is not the expert, the community is the expert.

So we should look to the community members. The work of promotoras goes beyond services covered in the new benefit. Being a promotora is valued and an important career, whether it is a step on a longer journey or if it is a volunteer in Visión y Compromiso, we say that a promotora can because of our curricula and our trainings and our leadership, a promotora can be the best promotora, volunteer promotora they want to be. Or they can apply for a job.

They can bring income into the family. The largest issue that can impact a family's well being is a job. You can buy with money. You can buy food. You can transportation, housing. But if we don't allow that opportunity for promotoras who may not fit the traditional mold. I do want to speak to one thing about the community colleges. While it is a good avenue, most of our community members aren't able to attend a community college.

There isn't one nearby, or they don't have the funds to apply, or the literacy rate is an issue. We know by example that Visión y Compromiso brings in a promotor that maybe yesterday was in the fields. They may not have a high school degree and they may not have 100% English, but they are the person that you want because they are in the community. They can reach the people that you want to reach, and they are as smart as heck.

My mother didn't speak English till the day she died, and if you were to put a job description out that said, must have a high school degree, speak English, you would not get my mother. You would probably get, as we have gotten before, an English-speaking non-Latina. And that defeats the purpose. So how do we bring those people in? Latinos have a high attrition rate in high school. Well, how do we bring those people in? Offer this as an opportunity. We talk about workforce.

We've been writing about workforce for probably 10 years now. Open the doors, look at a different way. It doesn't have to be the way that it has been forever. The compensation must reflect the value they bring to the communities and to our health care system. This is also a woman's equity issue. Most promotoras are women. Most promotoras, according to our data, are between 35 and 50. They're head of household or they bring income into the household. We want equity and pay.

We want compensation, fair compensation, benefits and retirement. Do you know that most do not even get benefits? Historically, they would do it for free or they would get a card, a gift card. It's an inequitable situation. Medi-Cal is also not the answer to sustainability. There has to be other resources because most community based organizations who promotoras are affiliated with are not Medi-Cal providers. So while it is a path, there has to be other ways.

And we think that by opening up this opportunity in all departments, whether there's a Medi-Cal stream or not, is a way to open employment opportunities and funding for CBOs, so the CBOs can hire promotoras. And most importantly, promotoras should be part of the discussion. They should sit at the table. They should be out. And their organizations, the ones who've been supporting promotoras for 20, 25, 30 years, who are the experts in the field, should be represented in this discussion.

This is our chance to build a sustainable system of community based care and support that has been proven effective over the decades. We recommend that there be a standing work group for at least the first year of the benefit rollout to ensure that community input continues to be central to this work. This is similar to the doula benefit that was mentioned earlier. Creating a benefit and workforce infrastructure built by and for communities is equity in action.

We're excited to be participating in this effort and we encourage you to look towards the experts in the field. We are sponsoring AB 3149 by Assembly Member Eduardo Garcia that would establish a Promotor Advisory Committee at DHCS, similar to the Doula Advisory Committee. We encourage you to look at that as an option and also to look at the promotor and the promotora as multicultural. Don't look at it as just as a Latina thing, a Latino thing. It is the heart of services in everyone.

This solution, the community health worker, the promotor is the solution in our communities and we should support it everywhere we can. Thank you very much.

Thank you. Thank you. We will next hear from Katie Andrew and I just want to remind everyone to please try to stick to your allotted time. Thank you.

Good afternoon, Madam Chairs and distinguished Members. My name is Katie Andrew and I am here on behalf of the Local Health Plans of California which represents 17 mission driven, not-for-profit, community based, locally governed plans that deliver equitable and accessible health care to over 70% of the 15 million Medi-Cal members throughout the State of California.

Local plans are very supportive of the community health worker benefit in Medi-Cal viewing CHWs as a community embedded extension of the broader healthcare team that reflects the diversity of the communities that they serve. Prior to the launch of the benefit, local plans understood the importance of CHW services and supported the education and training of the CHW workforce and directly employed CHWs to support care coordination as one example.

Local plans understand that CHWs are community members and trusted sources of information, allowing them to reach and connect with Medi-Cal members in ways that health plans and providers often cannot. They can meet Medi-Cal members where they are to provide culturally and linguistically, appropriate health education, assess needs, and navigate members to the care that they need.

Since CHW services have become a Medi-Cal covered benefit and knowing the value that CHW services can provide to the members, local plans have been engaging with CHWs and CBOs in the communities that they serve to develop a robust CHW network. While local plans are driven to ensure their members have access to CHW services, there have been a number of challenges since the benefit went live in July of 2022 that are contributing to a slow uptake in CHW services.

One challenge is there is a general lack of familiarity amongst providers and CBOs of the benefit, the services covered within the benefit, and how to utilize them.

To address this, local plans have undertaken several efforts to socialize the benefit amongst providers and CBOs alike, including delivering training and sending out communications to providers to help them understand that CHW services is a covered benefit under Medi-Cal and how they can refer their patients to services providing information to CBOs to help them learn about how the CHW benefit is constructed, the rules and parameters of the benefit, and how to become a contracted provider with local plans.

Additionally, some plans are utilizing in house CHWs to build relationships with local CBOs to promote CHW services and encourage member connections from local providers. Following the implementation of CHW services as a Medi-Cal benefit, the Department of Health Care Access and Information began a stakeholder engagement process to develop guidance and requirements for a CHW certificate program, which was paused in November of 2023.

As HCAI continues to conduct stakeholder dialogue sessions on CHW certification, many local plans have forged ahead, taking the initiative to implement efforts and build partnerships to train and certify CHWs, often incentivizing candidates through no cost programs or certification stipends and scholarships. Some local plans are also working to launch CHW placement programs and or offer salary stipends to entice potential supervising providers who may be hesitant to employ CHWs out of concerns around sustainability.

As an example of this work, one local plan is about to issue a $1.4 million grant through their community reinvestment fund to increase the availability of CHW certification programs through a partnership with California State University. The CHW training grant will focus on certifying 270 community members in the planned service areas through three year training grants. An additional $7 million grant will support the recruitment of CHWs, including one year salary and benefits costs.

Local plans have also experienced additional challenges engaging with CBOs who historically have not contracted with managed care plans and who have limited knowledge and experience with Medi-Cal, including provider enrollment, billing claims and other processes unique to managed care plans. To assist, many local plans have invested significant time and resources to build relationships with these organizations and their leadership and provide boots on the ground support through training and technical assistance from contracting through claim submission.

There is also the challenge of low reimbursement rates, which has led some CBOs to conclude that the rates do not align with the administrative requirements of being a Medi-Cal provider. And amongst CHWs, there's a need for additional support and technical assistance around requirements for becoming a Medi-Cal provider. As an example, some confusion regarding the provider application and validation for enrollment or pave pathway has bubbled up for some CBOs in local health jurisdictions for whom these are new processes.

Additionally, for some CBOs that may employ undocumented CHWs, there is hesitancy to enroll as a Medi-Cal provider born out of distressed of government entities and an instinct to protect their employees' information from government systems. Streamlining enrollment processes, administrative requirements and reinforcing how the state will protect those who are undocumented will help to alleviate many perceived burdens or hesitancy to provide services under the Medi-Cal benefit.

Lastly, while federally qualified health centers and rural health clinics have long hired and utilized CHWs for their services, restrictions for FQHCs and RHCs under the CHW Medi-Cal benefit impedes these clinics from leveraging the benefit to increase CHW capacity and therefore grow a statewide CHW network. FQHCs who are contracted with local plans and already engaged in the delivery of CalAIM services are best equipped to add CHW services to their clinical settings. This is particularly true in areas where community health clinics are the primary provider.

In contrast, under CalAIM, clinics are allowed to bill for enhanced care management services outside their PPS rate, essentially incentivizing clinics to participate in providing these services. While some clinics directly employ CHWs, not all do. Allowing them to bill for CHW services outside of their PPS rate would similarly incentivize community clinics to increase their CHW capacity and increase the number of CHWs that many local plans can then include in their network to serve Medi-Cal Members.

In closing, LHPC encourages the state to explore ways to include community clinics in the CHW benefit to further the goals of CalAIM and Population Health Management. We also encourage the state--

I'm sorry.

Thank you.

You can wrap up your comments.

Yep, I'm almost there. Provide state resources for technical assistance to provide organizations who must enroll in PAVE and ensure that provider enrollment processes are streamlined finalize CHW training and certification requirements and clearly articulate those to colleges, universities, and technical schools throughout the state through a coordinated and comprehensive communication campaign and finally, ensure comprehensive, clear, and periodic communication around programmatic and guidance updates for both plans and CHW providers. Thank you.

Thank you. Before we have the next speaker, I just want to acknowledge that Assemblymember Schiavo is with us.

All right, so we'll move on to our next speaker, and I'm just going to ask again to please stay within your five minute allotted time frame. We've got a lot of people on the panel today. Thanks.

Hello, Chairs and Community Members. I will have a title for today. Advancing the Dream, CHWSPRs and health for all in California. My name is Alexander Fajardo. I represent El Sol Neighborhood Educational Center, one of the oldest community based organization working with promoters since 1991 in the State of California. I want to share the work of a regional capacity collaborative in Southern California, San Bernardino, Riverside, Orange counties, and surrounding areas.

This collaborative was established in the GR 2022 to advance the dream of CHWs promoters contributing the goal of the health for all in California. This includes 80 providers representing public health and private health sectors and more than 200 CHWs. This collaborative was formed with two aims. First, to contribute the social justice lens into the CHW promoters representatives, integration opportunities reflected in the CalAIM and the Medical CHW benefit and secondly, to address a concerning trend.

As we celebrate the growing embrace of CHWs by the healthcare establishment, we want to address a concerning trend. Instead of letting CHWs to be CHWs, we saw institutions trying to make CHWs resemble a pre-existing profession that the establishment is more comfortable with. If this trend is not mitigated, the dream of CHWs promoters playing a key role in the help for all movement in California may be replaced with a nightmare of CHW's workforce drifting away from the social justice and system change routes.

Instead, they will become more accountable and aligned with the institution they work in and not with the community they are working in. For informing this powerful partnership, we have unite and share values with the following roots beliefs first of all, CHWs and promoters are community experts. The basis of their expertise is their vocation nor their certificate or credentials, neither if they are bilingual. Beyond conventional roles as a service providers, health educators, or coordinators, CHW's promoters and representatives are transformative forces capable of reshaping systems and structure.

Our collaboration is founded in the principle of co-learning and co-teaching, emphasizing that knowledge is a collective journey and that's what we are doing. No distinction between those who know and those who doesn't know, like doctors versus CHWs. I would like to mention a couple bright spots. Given the health disparities that we were highlighted during the COVID-19 Pandemic, more health organizations are working on health equity initiatives. Integrating CHWs into health institutions is a key strategy advancing these health equity efforts.

But also, this collaborative is working to address the reminding challenges many institutions having single aim and medical benefit as another funding stream to support the existent non-funded workforce, such medical assistance, health service assistance or nursing aides and not to hire or to sustain a transformational opportunity that only a truthful CHW can bring. Therefore, organizations are making CHWs and promoters fit into pre-existing institutions models and we have to transform that. CHW's work is more than a set of roles, titles or even a delivery service.

This is a movement to carry the hopes of marginalized communities. This movement has a healthy equity and a guiding value and legacy. In the name of the regional collaborative, we want to thank you for holding these hearings and we offer our willingness to work together to advance the dream of CHWs playing a key role in the health for all movement in California. And we hope that this model can be replicated with the proper resources and support to ensure these collaborative to have a statewide impact.

Thank you.

Thank you next speaker.

Good afternoon and greetings. Sorry about that. Good afternoon and greetings Chair Bonta and Assembly Members. I am Dantia Hudson with the Alameda County Healthcare Services Agency. As a public health professional, doula and lactation consultant, I am passionate about this work. I will share our experience that is based on a CHW training program in existence for over a decade, a peer advisor program as well as collective impact work. We created this program because of our passion to diversify the health workforce.

Despite the innovation we have made with technology and with AI in the health sector, the health disparity gap has widened. A 15 minutes office visit will not suffice. We must meet the most vulnerable individuals where they are sometimes outside of the confines of institutionalized medicine. I have directly seen the impact on communities of color disproportionately impacting black women in maternal health. For example, CHWs are a solution to health disparities.

We intentionally hire staff that reflect the students and patients in our community with a blanket of mentorship. We did all of this prior to CalAIM benefits, knowing years ago the need for this role to curb disparities. We are an existing model as an apprenticeship that is housed under Chabot College that serves individuals with lived experience. HICSA provides pivotal infrastructure, support and a pathway to employment within the agency.

We also partner with all FQHCs in Alameda County via the Community Health Center Network, community clinics, and our local county hospital and CBOs for employer placement. Over 100 participants have been trained to date, all with lived experience and cultural relatability. They receive community college credit and pay no fees for coursework. We also provide them with an $1800 a month stipend and guarantee on the job training. To manifest a patient impact in 2021. During the pandemic, we were experiencing vaccine hesitancy in multiple communities.

Our health coach CHWs were trained on COVID and deployed to two populations. A predominantly Spanish speaking school was less than 20% of students vaccinated and a Pacific Islander population was less than 40% of adults vaccinated. After a month of cross training by coaches, the percentages changed from 20% to 80% for the students vaccinated and 40% to 99% in the Pacific Islander community. At Highland Hospital, we conducted a study on high utilizers in the emergency room.

The coaches served over 280 frequent utilizers and connected them to a medical home with one on one support. They decreased ER utilization and increased medication compliance for 80% of users. They worked with recently incarcerated folks who, upon release, struggle to navigate chronic medical issues that were previously managed for them. The Assembly Health Committee asked for patient impact examples. We have numerous case examples on how becoming a CHW has changed the lives of those we've trained.

Not only does being a CHW lead to a career that they love with sustainable wages, though for some in the Bay Area more competitive wages are needed. It provided a training medium for first gen students who needed career exposure or hours prior to applying to nursing, PA and medical social work school. This is the ideal career entry to provide vertical movement within the health sectors. Some recent examples include BM, an African American female single mom who was laid off in 2022.

She enrolled in our program, secured on the job training with the community clinic and then a full time job with a local FQHC, making 23 an hour, then 25 in 2023. After a year, she is now a CHW manager at a CBO, making 80,000 a year. She has personally assisted over 500 patients. Another person, DC, a first gen Latino student with no career exposure, wanted to be a social worker but had no experience.

After completing the program, HICSA hired him and that experience led him to be hired as a substance use navigator with the Bridge Clinic. He now aspires to go to PA or medical school due to exposure he has had while on the job. Most of our graduates have a GED, yet they're working as complex care team advocates, CHW managers, and substance use navigators, helping thousands of patients a year.

We should not create educational barriers for those who really understand the community, speak the same language as our community, and prevent them from continuing to enter these CHW roles. HICSA was fortunate to participate in CHCF's regional CHW collaborative.

Based on our efforts through a learning community on CHW integration and direct experience, the state should consider the following, seed money for developing new programming at employer sites, infrastructure supporting CHW integration, including training for supervisors for this unique role direct support for CHWs who may have increased needs adjusting to the workforce or experience vicarious trauma, county and statewide marketing support to bolster recruitment programming for community for community health centers. We have helped hundreds of people who already do this work.

We also suggest advocating for higher reimbursement rates for MediCal benefit to support living wages in California, incentivize health departments to create a sustainable pathways and also that's it. Thank you for this opportunity.

Thank you, next speaker.

Good afternoon, Chairs and Committee Members. My name is Thu Quach and I am the President at Asian Health Services in Alameda County. We're proud to be located in the Chair Bonta's district. Thank you so much for inviting me to speak today. Asian Health Services is a federally qualified health center, an FQHC that was founded 50 years ago providing medical, dental and behavioral health to over 50,000 patients in 12 Asian languages.

We are also a proud Member of the California Primary Care Association, which represents 1,270 community health centers across the state. As a refugee from Vietnam, I was drawn to work here because of my own lived experience as a child interpreter for my parents as they navigated the healthcare system, the very complex healthcare system. I was among the very first community health workers hired for the youth program over 25 years ago.

At Asian Health Services, we've been encouraged by the state's recent implementation of CHWs as a MediCal benefit. Many health centers have been leaders in developing and including CHWs in our staffing models, even though we've been historically unable to be reimbursed for these services. Yet, unfortunately, however, even with this new benefit in place, there are many barriers for our FQHCs to access MediCal payments.

Even now, some of the challenges include that MediCal has implemented CHWs as a billable provider, except for when the CHW is working at FQHCs or rural health centers. For our FQHCs, MediCal's only reimbursement for CHW is accessed by undergoing what is called a change in scope of services request. This request seeks to adjust our payment rate from the state for all visits to include the cost of CHW services.

The problem with this is that the change in scope process is not a viable option for many of our FQHCs because it requires that the FQC to sustain the cost of CHW services without any rate increase for over a year, sometimes many years, while the department audits and finalizes the rate adjustment.

I also like to note that the department continues to have what's in place, a 20% haircut policy anytime we undergo a rate change, whereby any rate that the Auditor Deems appropriate, the Department would then reduce it by 20%. That's a lot. Given these challenges, we're requesting the FQHCs have the option to Bill MediCal for CHW services outside of our existing rates. CPCA has previously presented this option, which states such as Michigan, Kansas and Rhode Island allow, but were unable to get any traction.

I'd also like to note that the current reimbursement rate for CBOs is way too low as well. Historically, FQHDs needed to heavily rely on grant funding to pay for services rendered by CHWs. Some have been able to build robust programs that offer a career ladder for our CHWs, but most of us find ourselves having a CHW for a few years, then being forced to let them go due to inadequate funding, and then starting all over again when we're able to secure more funding.

I'd now like to tell you a few successful CHW programs at our health center. The Community Health Center Network CHDN of eight health centers in Alameda County created Care Neighborhood, which was actually the pilot that led to the enhanced care management ECM within CalAIM. Now, ECM is a program that targets high utilizers of hospitalization and other costly services.

In this program, our CHWs work closely with these patients to provide care coordination and other services, and in a recent analysis, we found that those served by CHWs actually are less likely, half as likely to enter into the emergency room or hospitalization. The exception here is that through this CalAIM program, we're able to get a per member per month reimbursement, which are really a game changer and allows us to really build our CHW program.

Another example is that Asian Health Services has started using community health workers become lay counselors. Given the mental health workforce shortage and the high demand for services after the pandemic, through a 63 hours lay counselor academy training, our CHWs are able to provide basic mental health counseling. As these CHWs are more culturally and linguistically aligned with the patients, we've seen that it significantly alleviated some of the access barriers, and we're finding that our patients are connecting with these CHWs much better.

We're asking for your support to allow FQHCs to be able to bill for these counseling services. On a broader note, I want to emphasize that FQHCs play a critical role in being the safety net for medically underserved communities, especially as we serve one third of all the MediCal beneficiaries. We would love to have more input during the planning process of these programs as they're being developed, and it would be greatly helpful with the implementation rather than having us ask for it afterwards.

Thank you very much.

Thank you. The next speaker? Yeah.

Committee Members Chair, Bonta staff my name is Dr. Mark LeBeau. I'm the CEO of the California Rural Indian Health Board. We represent 19 tribal clinics throughout California and 59 fairly recognized tribes throughout the state, from the Oregon border all the way down to the California Mexico border. CRIB is a workforce of staff providing planning, advocacy, funding, technical assistance, education, and development of tribal health program capacity across the state. We seek to promote unity and formulate common policies on Indian health care issues.

The Community Health Representative program provided through the federal Indian Health Service was established by Congress one year before I was born in 1968. It was established back then to help address the needs of tribal communities across the country. Back then, CHRs were initially focused on outreach to American Indian and Alaskan Native patients. Today, CHRs are trained in disease control and prevention, reducing health disparities, and helping to remove barriers to care in tribal communities.

CHR is our frontline workforce, focused on improving social determinants of health using a community based approach. While the federal Indian Health Service provides tribal communities limited CHR resources and funding, tribes in California continue to be among the least resourced in the nation. Cribb was excited to hear about the prospect of state providing reimbursements for CHR services. Unfortunately, the reimbursement level for CHR care does not cover the cost of administering the program and billing for these vital services.

In other words, the tribal health program's cost for CHRs to provide services, track these efforts, report to our billing departments, and bill for these services is far greater than the $26 per unit the state currently provides. Other states, such as Nevada and Oregon, pay tribal health programs quite a bit more. There's a term called all inclusive rate, 719 per qualified encounter for CHR type services.

While not all clinics can bill at the all inclusive rate, some states have acknowledged the severe health disparities that exist across tribal communities and have strengthened this workforce. To help address these challenges, CRIB has advocated for the all inclusive rate for CHR services. Here we continue to dialogue with our Department of Healthcare service partners on that topic, you may be aware, but tribal communities are generally located in rural and frontier parts of the state, contributing to our significant workforce challenges.

Besides the small populations and tribal communities, rural tribal health programs are among the most underfunded healthcare facilities across Indian country. While tribal health programs are exempt from SB 525. Given their ability to utilize sovereignty in that regard, they still face extreme challenges with competition staff moving to other clinic provider types. The support of an all inclusive rate would go a long way to helping to shore up the delivery of tribal health services in rural California.

Just want to underscore that I've had the direct experience of being served by CHRs growing up. My mother was a CHR of the Redding Rancheria. She was an elder later on in her lifehood. And I know that when an elder is in a community and as a CHR, the Indian homes open. We're trained to honor respect, adhere to the directives of our elders. So when you have older adults serving in that capacity, that goes a long way to the delivery of care.

That being said, like to encourage Committee to encourage our DHCs partners to work with CRIB and all tribal clinics in the delivery of an all inclusive rate, thank you.

Thank you,

Good afternoon Members and chairs. My name is Andrea Mackey, senior policy manager with the California Pan-Ethnic Health Network. CPEN is a statewide multicultural advocacy organization dedicated to the elimination of racial disparities and improvement of health outcomes for communities of color. I'm really proud to say that I lead the Community Health Worker Promotora and Representatives Policy Coalition alongside California Consortium for Urban Indian Health, the Latino Coalition for a Healthy California, the Children's Partnership, Transitions Clinic Network, Roots Committee, Health Center and Vision y Compromiso.

We are a statewide grassroots organization with over a thousand CHWPRs, many of which some of in the room today, advocates and allies to advance policies that impact our workforce. Make sure that they're rooted in community health worker promotora voice as we seek to strengthen healthcare quality, increase equitable health outcomes, improve financial sustainability, and prioritize workforce diversity. My commitment to community responsive wellness is rooted in my experiences as a mixed Filipina community health worker.

I provide diabetes management and education and connection to community resources from my Cababayan across Los Angeles, from San Fernando Valley to historic Filipino Town, following in the legacy of my mom and my grandma who were barangay health workers in the Philippines. In my culture, there's a lot of shame to be quite honest, with diabetes you know and often people aren't seeking care because the money that gets put into medication, is getting sent back home to the Philippines, or it's going towards rent or food.

And so I'm proud to say that when we culturally and linguistically tailor programs from the CDC link people to housing and medication assistance, we were able to decrease Emergency Department visits by 22%, reduce hospitalizations by 68%. I saw A1C's go starting off from 14, 12, 10. These are dangerous levels, drop all the way to seven, even 6.5. And without us, people wouldn't have gotten their blood sugars controlled for kidney transplants. They would have lost their vision, lost a limb due to amputation.

They honestly would have died. And my work isn't that special in that regard. You see it in San Diego with the neighborhood networks. They're addressing housing and food insecurity at 73%, Oakland root community health center distributed just last year alone, 10,000 COVID-19 test kits. So, as a policy advocate and as a CHW, it's powerful to see people transform from being passengers to drivers of their health. That's the energy of this workforce, the transformation of community.

However, as California continues to invest and develop policies for our workforce, it is imperative that we develop our own needs and rights. And so this year, the coalition developed a policy agenda for state leaders with four key themes, workforce development, integration, community access to CHWPR resources, services, and economic equity. As a culturally and linguistically diverse workforce, we are challenging racism in the medical field.

However, our ability to fully serve community is being stifled from providers, from state leaders, from healthcare teams who do not understand the work and scope of what we do. And if we want to see true success of the MediCal benefit, we need to remember the mantra that there is nothing about us without us.

There is a need to expand our services further where current healthcare systems has either ignored or harmed us, whether it be black, native, indigenous, Asian American, LGBTQ plus, specifically Trans and Latinx and rural communities. And most importantly, CHWPRs deserve economic equity. When you ask members of our coalition, only 10% say that their current salary covers their basic expenses, let alone the ability to thrive in our profession. Most of us are doing this at the service of our heart or the bione, the community spirit.

But the bione spirit is not paying for my gas, it's not paying for my rent at the end of the day. So while the new MediCal benefit offers this opportunity with sustainable long term funding, the proposed payment rates are barely getting us minimum wage. A recent study found that our current California rates are covering just 38% of actual cost. One Filipina I was talking to recently is wondering when are her wages are going to go up as the promise of this new benefit?

She's currently facing eviction with her son. The resources she was telling me that she's using with community, she has to use with herself. And this is not an uncommon story, particularly in Los Angeles. We are already paying out of pocket for materials and transportation. You are asking the same people who experience inequities and poverty to shoulder the burden that state should be paying.

So that's why with 1,000 plus community health workers and members, we asked the Legislature to raise CHWPR rates to at least 87.5% of Medicare. As we end this fantastic panel, I'd like to end with a Tagalog solidarity phrase, Isang baksak, which means one down, one fall onto the next. Today is a historic moment for California, and the rest of the nation is watching what we do here and how we respect our CHWPRs.

So together with CHWPRs at the front, our community, researchers, policymakers, let's plant the seeds to cultivate real change here to improve health for all Californians and rise up together. Thank you.

Thank you. I want to thank all of our panelists today and ask if any of my colleagues have any questions for this panel.

Just wanted to note and acknowledge that Assembly Member Waldron is with us today. Well, I want to thank the panelists for offering such incredible insights. And again, just to kind of reiterate my earlier point about the discontinuity, if you will, between the opportunity that we have and being able to work on the foundation that has already been built by your work over so many generations. Really, I want to put something in context for us.

So in July 2022, the CHW services have been a covered benefit in MediCal for fee for service and managed care. And the Governor's Budget assumed that there would be a total expenditure of about $91.9 million for the CHW benefit. We've all heard you speak to the incredible importance of this in terms of the advancements and disparities, and I love hearing Isang Baksak as a way to be able to really lift that up.

The reality is that because of these, I don't know, friction points or opportunities, growth opportunities for us, we have only been able to spend out $3.4 million or have a utilization of $3.4 million for fee for service and less than $1 million for managed care. So the opportunity for us to really be able to focus on integration is incredibly great. We want to see us hitting that $91.9 million of utilization levels.

So I would probably just orient this question to a couple of panelists just to be able to get some talk on this. And I want to thank my district panelists, Ms. Quach and the Alameda County HCSA, for participating with Ms. Hudson as well.

Where are we falling short in terms of ensuring that the managed health plans are providing the kind of accountability, or how are we falling short on accountability in terms of ensuring that you have the training, the ability to fully reimburse, the ability to structure your funding for community healthcare workers in a way that is a thriving wage.

How can we shorten, or I should say accelerate the opportunity to deal with some of these friction points that you all have laid out that's keeping us from providing this crucial opportunity for people and just maybe two or three people. And I think anyone can answer that.

I would love to. This is Maria. And I think historically the plans and the institutions rely on what they've known. I think I mentioned that before, this is an opportunity to engage community, the community experts in solutions. Community has been providing solutions free of charge. When I walk out the door and I need a resource for exercising or I need a resource for information, I go to a community based organization. They exist across California.

And I think the agencies, planned states, clinics need to really reach out and embrace the community as a partner, as a dotted line, not only to workforce, as we increase the numbers of expertise with promoters and community health workers, but also as a link to resources and to solutions. Clinics, plans and hospitals can't do it all. There's just too many of us.

And so we have to reach to community and also to look at diminishing those barriers to including community members, looking at who we are and the gifts that we come and how can we accommodate those persons without the mainframe that we've usually looked at and ask us what that should look like.

Ask us community all at the table. What should it look like? How can we get more community interested? How can we get more to be hired? How can we train more? How can we reach more community should be a partner in that.

I wanted to add for an FQHC. I spoke about us being written out and really trying to go for a scope change, and I think that just doesn't work. We have the job descriptions, we're paying them higher than minimum wage, much higher. They are part of the fabric of community health centers. But we are relying on philanthropy to fund a lot of that.

And I think where the example that has been very successful that I spoke of is the ECM, where there is a workaround, where there is a per member per month. And I'm telling you that now we're actually doubling the number of CHWs and feeling very confident about that. And we're showing that they're keeping them out of the hospital, keeping them out of the emergency room. But ECM is very limited. It's focusing on the highest utilizers. Those are really impacted.

But if we can grow that to more of a preventive lens, I think you'll see that there's going to be a lot more money saved. So I think in looking at this, at least from a FQHC point of view, we've always had community health workers paid part of our job, but we need an infusion that is sustainable rather than choppy through philanthropy.

Thank you.

Thank you so much for that. And I was just speaking with Chair Bonta. The number is actually 3000, not 3 million. And so it's actually worse. As far as our utilization based on the amount of funding that has been allocated in this area. I have a couple of questions.

Dr. Alex Ferrato, sorry, you had mentioned something about the fact that community health workers were being asked to kind of change, to kind of assimilate into the environment rather than allowing them to be themselves and their own experiences. Can you elaborate on that a little bit more?

Thank you for the question. Yeah. What we have noticed with this benefit is how has been integrated CHWs into the system. Because what is happening is everyone right now, with the funding that is available, is trying to work out how to use. So what is happening is many unfunded positions like nurse aid or medical assistance have been going to a training to get the title, and now I'm CHWs and now I'm billing so I can cover that position.

I think that's kind of what we're trying to say, that it has been losing the identity of the CHW. So a training is important to develop the skill of the existing heart, of the passion that person has of the relationship that person has in the community, versus just having the title and doing the work. So I think that's kind of the risk that we're seeing.

And as a coalition, we have been noticing and we're trying to see how we can work together to making sure to protect the identity of the real CHW. So I want to mention, and also I think expanding a little bit of, I'm assuming the money is there is because it's not enough to cover. So I train 100 CHWs, for example, how we're going to be sustaining this workforce.

So I think that's the risk of training too many people that we're not going to be able to sustain with the existing rate.

Can I just add to what Alex just mentioned? I think also historically, plans, clinics and hospitals will define those positions. Historically, the plans, clinics and hospitals will define the community health worker position according to their needs. Gathering data, input forms, those kinds of things that are not related to the work that they're really intended for, which is education, outreach, navigation, and support.

And I think that's part of what complicates the issue when we get into who's hiring and what are the requirements for that position and who gets hired for that position. Those are barriers that exist, have existed for a very long time.

Thank you so much for that.

Well, thank you so much for coming out to share this. I think, again, it's an incredible opportunity. We want to be able to build on your work. We're glad to be able to hear from practitioners directly and we'll certainly take this under advisement as we continue to build out, both legislatively and from a budget perspective, our programs and provide the oversight to our agency. So thank you for coming and being such an incredibly diverse and expert group of panelists.

As we are going on to our third panel which is implementing the CHWPR services and workforce in California successes, challenges and opportunities, we invite Michelle Baass, Director of DHCS, and Renee Malo, Deputy Director of DHCS to come up. I want to thank the Department for their efforts in creating the CHW benefit and for your ongoing work to ensure these benefits are real for MediCal members.

Obviously, the take up of the benefit has been slow and I'm very interested in what we are doing moving forward to make sure these services are offered. It seems like more needs to be done to get plans to focus on this benefit and we want to hear about that. DHCS has said it will continue to identify ways to provide further guidance to plans to leverage the CHW benefit. What does this look like? Will this guidance have binding requirements? Will it just provide encouragement or best practices?

These are some of the questions that we want to be able to get to. With that, we will begin with Elizabeth Landsberg, Director of HCAI, and then move on to Libby Abbott, Deputy Director of HCAI. Oh, sorry. Director Baass, sorry.

Good afternoon, Madam Chair, mambers. Michelle Baass, Director of the Department of Healthcare Services. As really noted by almost every single panelist today, we see huge opportunities with the community health worker, both benefit and actual workers, as they can be effective with a variety of populations as well as in diverse geographic settings. They can provide valuable link between underserved communities and the hospitals and clinics and other healthcare systems located within them.

Their deep familiarity of social networks and community resources which may be less familiar to the kind of the core healthcare professionals and so really bridging that cultural and socioeconomic gaps between clinical professionals and the communities they serve. CHWs have been providing services to MediCal members for some time.

For example, many of our MediCal Managed Care plans have historically employed CHWs for health education services, may also be members of care management teams and other programs, including the complex care management service and the enhanced care management, as was spoken about earlier today. However, we do acknowledge that more needs to be done to really maximize and elevate CHWs in California's health landscape. It's been decades creating the system we have today.

And really all of our efforts with regards to the transformation of MediCal, really identifying ways we can broaden our healthcare landscape to include community-based organizations, really meeting our members where they are, and we really see the community health worker benefit as integral as part of this. As noted just a few minutes ago, actually since implementing the MediCal benefit, approximately 5500 MediCal members have received services from CHWs, resulting in nearly about 9000 CHW benefits.

We would want to note that this does not include really the community health workers that are being utilized in other settings, such as the enhanced care management benefit. We know that our enhanced care management providers are using community health workers to provide the outreach and education services, which is one of the core seven components of the enhanced care benefit. And so those numbers are not reflected in the pure CHW utilization. We know, just for example, just a conversation last week, site visits in LA County.

Some of our enhanced care managers, such as partners in care, are really layering on CHW services and benefits as they implement enhanced care management. So we really see a huge opportunity as the enhanced care management gets built out. I would note just in terms of the estimate that you noted, that was based on kind of projected utilization of the community health worker benefit back in 2021 as the proposal was implemented.

And we know we still have a lot to do to kind of build it out to that capacity, but that was a very initial estimate of what these opportunities might be.

I would also note that in terms of our FQHCs, really the alternative payment method proposal, kind of that proposal to really rethink about how we pay our FQs was intended to address this, to provide our clinics the opportunities to provide flexibility in their care delivery models and not necessarily need to use billable providers such as physicians to provide care in our clinics.

And so seeing that as an opportunity without having to do a scope change to really recognize the value of community health workers in our clinics. I would also note that some of our MediCal Managed Care plans are intending and thinking about piloting of where they would contract with community-based organizations that would sit within FQHCs to really provide some enhanced community health worker services in our FQs.

I wanted just to highlight, I know that many models of how CHWs can be used in our healthcare delivery system were cited in reference today.

I wanted to highlight an example that we think is one like a very just a great best practice and a really innovative way of thinking about how county departments can maximize their use of CHWs so Riverside County and the Inland Empire Health Plan and MediCal Managed Care plan are really partnering to have the Public Health Department essentially serve and the Health Department serve as a hub for community health workers in the counties.

Their behavioral health department, public health, they're considering aging, they're considering EMS, emergency services, how they can use this benefit as part of their entire county delivery system. You know, just one of the things that they already have kind of are starting to develop in terms of their Department of Public Social services. So their local department that operates the Cal Works Welfare to Work program, developing an apprenticeship program so that individuals in the Welfare to Work program have a path to become a community health worker.

They have hired or they're in the process of hiring one individual who's going through that pathway to really support kind of within Cal Works and Welfare to Work. How can we build up that workforce in that space in a county and really just some innovative partnership between the Riverside County and Inland Empire Health Plan.

Just wanted to highlight, there are lots of kind of very inspiring models out here in the state and really looking for ways to lift up these models, push our managed care plans to think about this, push our local health jurisdictions to think about this as well as we try to maximize really great jobs in our community as a result of community health worker services.

I will now turn to my colleague, Renee Malo, Deputy Director, to really talk a little bit more about some of the kind of the questions that were raised.

Good morning. Good afternoon, Madam Chair and members. So, again, I just wanted to highlight a couple of things that we're doing at the department in support of the community health worker benefit. A lot has been discussed today by other panel members, so I'll just be brief in my remarks and welcome your questions at the end. So in terms of member and provider resources and materials, we've done a lot of work in terms of developing a website for information about CHWs.

We have put out information in our MediCal provider manual that talks about the benefit, the scope of the benefit, and how those services can be billed from the department. We've also put out a provider bulletin regarding the benefit, as well as an all-plan letter that was referenced earlier that gives detail to our managed care partners in terms of the benefit that is made available to MediCal members.

And we also have a dedicated email inbox that can be used by providers, members, and others to submit questions to the department regarding the benefit. One of the things that was stated earlier was about making sure that we involved the voice of the community health worker. When we worked on the development of the benefit. We did hold a stakeholder workgroup effort and wanted to hear from people in terms of the benefit and how it should be structured here in California.

So the benefit and its structure in terms of the training and the certification was informed by voices from the community dealing with community health workers we have been providing technical assistance to our managed care partners and we have provided at least 60 sessions to date that include weekly plan calls with them as well as specific CHW focused webinars. With our plan partners. We will also be partnering with CPIN to host some sessions for our managed care plans and for providers to attend.

One session will show about the managed care contracting process to help familiarize providers, and then the other session will be to show providers the perspective from CPEN's membership in terms of the use of community health workers. And then we're also hoping to partner with California Healthcare Foundation to showcase their CHW toolkit.

We do value the collaboration that we have with the stakeholders in this space because we do think it's important in using them to help with the training opportunities that we offer to our managed care plans and our providers.

And we are also, as will be mentioned here shortly, collaborating very closely with HCAI and with our agency in terms of a series of community dialogue sessions that are underway and will be occurring over the next six months to better understand and to strengthen the capacity of community health workers, the promotoras and the community health representatives, and to help with the uptake of the benefit in the MediCal program.

It is really important to us to hear those voices so that we can then pivot and make modifications and or additional training materials available so that people can help to understand this benefit under the MediCal program. And I will state that given the time of implementation, it does take time for new benefits to be realized in the program. But we are really working very diligently in terms of helping to increase the awareness and the uptake of that benefit.

I will note one question that was posed to us was about the use of the new codes that are under Medicare and with the Medicare codes as it relates to the MediCal program. We believe that, and we've looked at their codes. We believe that the way their codes are structured are a bit more restrictive than what they are under the MediCal program.

For instance, one of the codes is only billed on a monthly basis, whereas our codes are billed based upon time increments and they can be billed up to a certain amount in a particular day for individuals. So we just want to make sure that as we're looking at this benefit, that we don't introduce new policies that may be more restrictive than what we already have in our program today.

And with that, that will conclude my comments at this time and look forward to any questions that you all may have. Thank you.

Thank you. So now we'll hear from the Director and Deputy Director, respectively, Elizabeth Landsberg and Libby Abbott from the California Department of Healthcare Access and Information, HCAI.

Thank you very much. Good afternoon to both Chairwomen and members. Elizabeth Landsberg with HCAI, the Department of Healthcare Access and Information. So we are committed with all of our health workforce programs to diversify the health workforce. To have it be more representative of California in terms of race, ethnicity, linguistic skills, cultural diversity, and diverse in its lived experience. And investing in community health workers is key to that mission work.

The agenda and the testimony we've heard today powerfully describe the role and impact of CHWPRs in improving health outcomes for California's communities. We also think that supporting the training of CHWPRs offers healthcare employment opportunities to people from marginalized communities who might not otherwise have access to traditional training pathways into the health workforce.

So we believe that by supporting and expanding the CHWPR workforce, we're both advancing access to quality care, building the diverse workforce that we wish to see in California, and addressing the systemic lack of equity we've experienced in California's healthcare system. Our overall aim is to expand and support the CHWPR workforce in California to increase access to care for marginalized communities, and to do so by supporting the recruitment, training, and certificate process for CHWPRs.

So, to achieve these goals, we're currently undertaking a process to hear from stakeholders, including, very importantly from CHWPRs themselves, on what our specific interventions and activities should be. We're approaching this with an open mind and a willingness to invest in innovative and community-informed solutions.

So HCAI was charged in the 2022 budget to develop statewide requirements for CHW certification programs in consultation with stakeholders, to approve statewide requirements for certificate programs for CHWs, and to review and approve the curricula for core competencies, the specialized programs and training. So we have already engaged in significant stakeholder engagement and design process to meet those requirements. We started with meetings with 26 stakeholder organizations to hear from those with expertise in the space, including many of those we've heard from today.

Last spring, we had 43 stakeholder engagement sessions and heard from more than 1500 individuals, including many CHWPRs across the state. And those folks gave input on the design of the state's certificate. All session types either offered Spanish-only sessions or had live Spanish translation, and we also offered the opportunity for other language translations.

So based on the feedback from those sessions, we did last July issue a guidance letter with the statutory requirements around the certificate program and the training, and as you know, that has now been paused.

Despite the heavy engagement that went into this process, we heard from some in the community that they felt their feedback had not been adequately heard or addressed, and that is what led to the pause and implementation of the guidance letter that Secretary Galley alluded to and the second round of community dialogues that is ongoing.

Thank you, Elizabeth and good afternoon, Chairs and members. Following the pause that was announced in November 2023, the state team, comprised of California Health and Human Services Agency, DHCS, and HCAI, has been working with consultants to design a stakeholder engagement process that would go deeper to leverage community expertise to determine how best to meet our state requirements. In February, we launched our second round of stakeholder engagement, through which we will conduct over 20 dialogue sessions with CHWPRs, their allies, and employers around the state.

The overall aim of the dialogue process is to get stakeholder feedback on two basic questions, how can the state best use its funds for recruiting, training, and certifying CHWPRs?

And how can the state design and implement a state-approved certificate to support and advance the CHWPR profession in California, we have selected dialogue sites with attention to addressing both geographic distribution and coverage of the wide range of types of CHWPRs and the communities that they serve, such as Latin communities, tribal communities, black communities, unhoused individuals, and justice-involved populations.

We are prioritizing input from CHWPRs themselves, but are also designing dialogues for the CBOs, health plans, and health systems that work with CHWPRs to ensure that we have a holistic view of what is needed to expand and support this workforce and integrate them sustainably into team-based care. An earlier panelist raised that we need a formal space for consultation with CHWPR to drive our efforts as a state, and that feedback is well heard.

In late February, we kicked off an ad hoc advisory workgroup comprised of key organizations and thought leaders in the CHWPR space, many of them in the room today, and collected feedback from this group on our dialogue guide, process, and site selection. We will continue to engage the ad hoc advisory group regularly every four to six weeks over the next few months to ensure that our process is comprehensive, relevant, and appropriate.

We intend to formalize a working group in the coming months and will open applications to the group reserving dedicated slots for CHWPRs themselves. In this budget year, HCAI has $15 million to support CHWPR programming. However, we heard the message from stakeholders that our design process needed to be more comprehensive and holistic and so have paused implementation of that funding while we go through a more robust stakeholder engagement process as I just described.

The results of our stakeholder dialogues alongside consultation with the advisory group will inform the allocation of HCAI's $15 million in budget year 23-24 and remaining funds, including $188,000,000 in 2024-25 and 57.5 million in 2025-26. We expect to wrap up our dialogue process this summer and begin programming funds in late 2024. HCAI has expenditure authority through 2028 for these funds.

Separately, earlier this year, Visione Compromiso received a $10 million contract as a one-time legislative augmentation through HCAI to strengthen the state's infrastructure and support for promotoras, community health workers, and community-based organizations, including through building CBO hubs and assessing training needs. At HCAI, we hope to learn from Visione Compromiso's work and integrate their findings, lessons learned, and good practice examples into our funding strategy.

So we're deeply committed at HCAI to supporting the training of CHWPRs and their effective incorporation into team-based care. Very helpful to hear from the plans, from the clinics, from the community-based organizations, and it's going to take deep collaboration with all of those groups and primarily listening to CHWPRs to set up the systems that we need to truly support this benefit as we need to do moving forward.

Thank you. I'll open it up to my committee members. Dr. Arambula.

Thank you so much. I'm going to begin with Director Boss and Deputy Director Malo, if I can. I want to focus on the all-plan letter that went out. I'm trying to get an understanding about whether or not our plans are meeting our expectations or what expectations we've placed onto them at the moment.

What's our expectation for them to ramp up and have CHWS as a benefit that is meaningful, as the integration plan or integration plan seems to not inherently have a network that they have to declare. So I'm trying to get an understanding what's reasonable for us to expect in terms of a ramp-up and in terms of a sufficient network that we're asking the plan. As it seems you have the tools both for a carrot and a stick.

You have an incentive payment plan as well as the opportunity to do some corrective action plans to these MCPs that I'd like to understand how assertive or aggressive are we being in making sure that we're getting this up and running as quickly as we can.

So with regard to our incentive payment program, so these are dollars kind of based on kind of reporting of utilization on CHW services, the first round did not produce the sufficient data or the data that we thought it would produce. We know that the plans are rerunning the data for the next round of submission and we will be closely watching that they understand the importance of true submission of that information.

We know encounter data often lags, but the importance of really getting a true understanding of what is available in the state is something I think that we will have as baseline to really kind of understand where we're at today. We don't have specific requirements like we have for some of our other professionals with ratio requirements. We don't have that yet.

I think this is really understanding kind of where we are today and where we can get to and having the conversation with the communities and all of the stakeholders involved to understand where we want to get to. And I think part of it too is understanding where community health worker services are being provided that's not reflected in the encounter data. We know that they're being provided through ECM.

We know that they're being provided in clinics based on kind of their practices for many years of using the community health worker service kind of as part of what they provide in an FQ. So there is a little bit of understanding of what do we have today that may also not be reflected as part of just encounter data reported by our managed care plans.

The last panel spoke so articulately about the benefit that we see financially to investing into our CHWPS, that our plans should be wanting and willing to take this up. And it's a bit shocking that we're not seeing the implementation that should be expected with the benefits that are before us from research.

And so I'm just trying to make sure we're using all the tools that we have to get the plans to be implementing this as quickly as we can and just want to make sure we're doing just that.

And I would note also just I think about our bold goals, 50 by 2025, and the focus on prevention and primary care, maternity care and birth equity outcomes and behavioral health integration. And those are kind of those metrics that we monitor every year. And that's where we are holding our plans accountable with regard to sanctions, financial sanctions, and recognizing the only way they are going to meet those metrics and make improvements is an investment in community health workers.

And so I think everybody understands that really important link there. And we have kind of our ways that we monitor our managed care plans in terms of quality that will be reflective of their use of CHWs.

Final question, Madam Chair. So those priority areas that we've identified from those bold goals, are we meeting capacity for CHWs in those priority areas for behavioral health, integration into primary care, Children's Preventive Services, and maternal outcomes? Are we at least focusing on those three priority areas initially, or are we just getting started?

So in terms of just overall managed care compliance and oversight, this is the second year of kind of quality sanctions that we've implemented as part of our kind of oversight of our plans. And so this is year two. There's no specific metric related to community health worker utilization. But recognizing the importance of community health workers and achieving some of those goals, particularly with the equity lens, I think everybody is committed to and understands the important link there.

Can I pick up on Dr. Arambula's question a little bit? So are there specific benchmarks that you are intending to roll out related to the community healthcare worker kind of growing of the network? That can be a little bit more of a guide besides what we have.

So I think we're too early to be able to set ratios or to kind of come up with pure standards like we have for physicians and specialty. Those took years to kind of develop and understand kind of what's available. But I think it is something that we are thinking through in terms of kind of what does a network mean for community health workers, what should utilization look like?

So I think it's part of these ongoing discussions as we continue to kind of increase utilization or push to increase utilization.

Do you have a sense of what the timeline would be for you to be able to set those benchmarks?

We do not at this time. I think, as Director Baass has said, as we continue to educate and build up that workforce, and we recognize that there are community health workers out there today doing this type of work. What we've also learned is that their engagement with the Medicaid program is new.

And so that's a bridge that we have to cross, and we have to address the concerns that they may have in terms of their desire to participate in our programs, as well as the work that we're doing to help support the use of community-based organizations and local health jurisdictions in terms of enrolling in the MediCal program as a provider type. So as we have launched these new initiatives, we've also developed training tools and as we're hearing questions from them. We're making refinements in those tools.

But that will all take time because it is a paradigm shift for us, and it's a new way in which we're doing our business in the Medicaid program that's outside of the traditional healthcare system. But again, in the communities, these have been services and supports that have been out there, but they have not been formally recognized per se, say, in the Medicaid program. So there's a groundswell there, but it will take time.

I think it might be helpful to think about some of the leading indicators that we can tie some metrics around. Just early utilization, increasing that number. I just continue to know that we have such an incredible dearth of culturally and linguistically concordant healthcare workers. We have an absolute golden opportunity now to be able to take advantage of this, because it's a defined benefit, and we know that we have 25,000 workers that need to come online.

So anything that would allow us to have a clear roadmap around how we are going to do that with some metrics would be incredibly helpful for us just to be able to mark time.

Thank you. And along that route, do we have a roadmap as to what is the outcome that we're looking for when we're talking about improving health outcomes? Do we have, as we're putting this program together, do we have an idea of what are the outcomes that we're looking for to determine whether or not this is successful, if it's something that we should continue to fund, if we should, in the future fund more, continue, do we have that? Or is it just kind of a blank slate?

So, for the Department of Healthcare Services, our comprehensive quality strategy, where we outline our bold goals, 50 by 2025, that is kind of our roadmap on the kind of the metrics we want to monitor, the disparity reductions we want to see by a certain date. And that is kind of the global framework for what we're trying to achieve. And everything we're doing is really in alignment with that.

I even think about the equity and practice transformation grants, all of our investments, all of our kind of monitoring is in alignment with our comprehensive quality strategy. So I would say that is our roadmap.

And so at some point in the future, you'll be able to compare communities that benefited from these workers versus communities that didn't, to see if there's a difference in the health outcomes for these specific areas that we're looking at, primary care, maternal health, behavioral health.

I don't know that we would be able to draw a conclusion that the use of community health workers made a difference because we're making investments in so many places with regard to achieving these objectives. And so isolating community health workers versus targeted rate increases for primary care, there's a whole host of things that are going to drive towards the quality improvements that we're working towards, and so isolating each of those individual initiatives, I think, is going to be difficult to do.

Well, how will we know if it's successful then? If all of the other variables are the same in a community and one has the benefit of community health workers and the other doesn't, and that one that does has much better health outcomes, lower hospitalization rates, improved hemoglobin A1C levels, blood pressure. I don't understand how you wouldn't be able to extrapolate that.

I think there are lots. There's the equity practice transformation grants, the targeted rate increases, community health workers. We have doulas, we have the dietic benefit. There are a lot of things that we've done over the last few years that are directly related to what we're trying to achieve and being able to isolate how much each one of those contributed or did not contribute to a health outcome. I think it is difficult.

I don't know that we have the capability at the department to isolate it in that sense, but happy to continue conversations on that.

And in terms of HCAI's goals, it really is a workforce development goal. I just want to say the 25,000 was originally when there was a $350,000,000 proposal. But we are setting specific goals for reaching the whole state, and we know that there are some training deserts that really need to be addressed. But we are working to develop that racially and linguistically diverse community health worker workforce for the entire state.

Thank you, Director. I look forward to having more conversations with you about this.

Thank you. And I think I just, again, want to just recognize that we have some serious deserts right now. I'm very thankful to be in a district where we have a lot of opportunity and have a very strong infrastructure. I'm very concerned about the Central Valley in particular, for not having the kind of infrastructure that we need. So is there anything that you all can speak to around amplifying the need to increase the training opportunities in our healthcare worker deserts?

Yes, absolutely. So, as you know, Madam Chair, HCAI both develops. We have the methodology to identify the medically underserved areas. We're pulling together a lot of the workforce data, putting out with our research data center, the areas that are medically underserved. And so we are going to be focusing, and Ms. Abbott can talk in more detail about how we're going to be focusing on those medically underserved areas.

And I would just say that I mentioned earlier some of the funding amounts that we have available, notably 188,000,000 for the next budget year, and it's somewhat flexible to recruitment, training and certification. So we absolutely do plan to address gaps in training. We've heard from some of the CBOs and stakeholders in the space that there aren't enough training opportunities to generate the supply that's needed for the service demand. So we're working very closely, hand in hand with DHCS as they work on the demand side.

It's our responsibility to address the supply and make sure that there's adequate training opportunities. So we'll be using our funds based on the results of our dialogues and targeting areas with greatest need.

Thank you. I want to be mindful of the time and of my colleagues schedules as well as well as yours. So thank you all for coming and presenting to this hearing. It's been very helpful. I'm going to ask my Co-Chair here if she has any closing remarks.

I will be brief because I know it's late in the afternoon. I just want to thank everyone who came out. I want to thank all of the panelists for expressing your interest, your concerns, and your ideas for how we as a state can do a much better job at rolling this out so that we don't have deserts.

We're able to improve on a lot of these disparities within our health care system and ensure that all Californians, regardless of where they live, their socioeconomic status or their ethnic background, is able to be healthy and create very healthy families. So I want to thank Chair Bonta for putting this panel together and look forward to continuing conversations with the departments to ensure that they are listening to the community members, thank you.

Any comments from my committee colleagues? Well, thank you so much, Dr. Weber. Thank you for the participation and making sure that we have an opportunity to work together. It's been quite fun, actually. You're a cool woman, Dr. Weber. With that, we will welcome public comment. Now, in just a moment, I will say that we are hoping to keep public comment down to 1 minute.

So as I just offer some closing remarks, please form a line at the microphone with 1 minute to be able to share your thoughts. I'd like to conclude this hearing today on a hopeful note because I hear broad agreement among all the parties here about the value of CHWPRs and the services that they provide and the desire to expand and better integrate this diverse workforce. However, hope is not always the strategy that we can rely on.

It is our job collectively to ensure that we can strategically move forward. And let's not forget the why. The why is because we want to desperately and need to have the workforce that is going to address health-related social needs, improve the cultural, and linguistic concordance of the health care system throughout, and improve health equity and outcomes, and to be able to really, truly build on the work of those that have come before us at scale for the state.

So with that, I wanted to just indicate that we will continue to work on this and really appreciate the public's engagement around this. And I understand that there is going to be a bit of a celebration a little later today. And my goodness, are the folks who have been doing this work for so long deserving of a celebration to be able to move our progress forward. So thank you. With that, we'll start with our public comments. I have my little timer here. Thank you so much.

Name, affiliation and less than 1 minute comment.

Hi there, thanks for allowing and what a wonderful hearing today. My name is Kelly Bennett. I'm the CEO of Community HealthWorks right here in Sacramento, formerly known as Sacramento Covered, but we renamed ourselves after our workforce of community health workers who, we have 130 that are working in hospitals, clinics, jails, encampments, schools, employment centers, et cetera. We've just recently officially certified our 1st 22 with an amazing training from El Sol who was here today in partnership with health plan funder.

We are operating very robustly in the CalAim space in both ECM and CS and that seems to be with all the headaches and barriers of that program moving along quite well. We are contracted with four managed care plans here in Sacramento and one item that did not come up in the conversation today is I just like to make a plug for the experience track certification of long-standing community health workers.

We are awaiting guidance and a mechanism to grandfather those of our community health workers that have been operating for many years and serving the community, and we don't currently have a mechanism for certifying them. So just want to make a plug for that. And for a livable wage, we are paying our CHWs $25 an hour plus benefits and retirement to start right out of the gate. We're very proud of that. We need a rate structure that supports that. Thank you very much.

Soy promotora comisión y compromiso voluntaria por más de siete años y estoy muy orgullosa del trabajo en el cual me dedico. Gracias por por su trabajo para incluir los servicios de promotoras como un beneficio para los pacientes de medical. Me gustaría compartir una historia que mostrará por qué las promotoras son únicas en el sistema de atención médica. Como promotora me ha tocado llevar a familias con sus bebés a los hospitales con problemas del asma así casi muriéndoes por no poder respirar y sin saber qué es lo que les está sucediendo a su cria. Porque es la hay barrera con que se encuentran ellos estas familias son que el personal del hospital no habla su idioma y las familias desconfían de l hospital por su estatus migratorio o por otras razones. Yo tengo sesenta y nueve años y al llegar al hospital al hospital de emergencia, me pasa igual y en los consultorios médicos, pero aunque no hable el idioma mi experiencia como promotora me da la fortaleza y confianza de poder abogar por estas familias y por mi misma. Mis entreanmientos de promotora me ayudan a navegar los consultorios médicos y me ayudan a eh, empatizar con estas familias y ganar su confianza para poder ayudarles a buscar atención médica.

Sin embargo las tarifas actuales que se proponen en las complejidades involucradas en la contracción y facturación de la atención administrada probablemente por obra prohibirían que muchas organizaciones comunitarias participen en el beneficio.

I'm the translator. Hello, Madam President and Assembly Members. Thank you for having us today here. My name is Anna Lettie Hernandez. I have been a promoter with Vision y Compromiso for more than seven years, and I am very proud of the work to which I dedicated myself.

I like to share a story that will show why promotoras are unique in the healthcare system. As a promotora, I have had to take families with their babies to the hospital with asthma problems, almost dying because they cannot breathe, and without knowing what is happening to their baby. The barrier these families face is that the hospital staff does not speak their language and the families distrust the hospital because of their immigration status or for other reasons.

I am 69 years old and when I arrive at the emergency hospital, the same thing happens to me and in the doctor's office. But although I do not speak the language, my experience as a promotora gives me the strength and the confidence to be able to advocate for these families and for myself. My promotora training helps me to navigate doctors offices and help me empathize with these families and gain their trust so I can help them seek medical care.

Thank you for your work to include Promotora Services as a benefit to medical patients. However, the current fees being proposed and the complexities involved in contracting and billing managed care will likely prohibit many community based organizations from participating in the benefit. We urge you to include community based organizations and promotoras in your deliberations on how best to implement these services.

As we saw during the pandemic, these are the healthcare workers who can help health problems and initiatives truly reach the people they are meant to serve in our communities. Thank you.

Thank you. Just one minute please. Moving forward for the next speakers, just remember that we're trying to stick to one minute. Thank you.

Buenos tardes, señores y señoras asambleístas, soy promotora de vision y compromiso mi nombre es Norma Yadira Gallegos. Gracias por darnos la oportunidad de presentarnos hoy aquí quiero compartirles mi experiencia como promotora voluntaria. En diferentes actividades de la comunidad tenemos el acceso a la información de recursos programas que son de gran beneficio para las personas que son de gran beneficio para las personas especialmente para las vulnerables de la comunidad y no solo en servicios, sino que en todas las areas incluyendo especialmente el area de salud educación apoyo ayuda emocional vivienda y trabajo. Para mi es muy grato ya que es un trabajo de gran empatía y amor y apoyo al desarrollo personal familiar y de la comunidad. Es un privilegio ser promotora porque antes de ser promotora no sabia a quien acudir o confiar. Mi trabajo como promotora me ayuda a aprender sobre servicios disponibles para mi para mi familia y la comunidad. Les incitamos a que incluyan a la organización comunitaria y a los promotores en sus deliberaciones sobre la mejor manera de implementar los servicios en beneficio a la comunidad gracias.

Hello. Whitney Francis with the Western Center on Law and Poverty. We support the request to raise the medical reimbursement rate for community health workers, promotoras and representatives using previously allocated unspent dollars. These workers play a key role as trusted partners in supporting Medi-Cal Members in advancing health equity. Thank you.

Good afternoon, Chair and Members. My name is Gabriel Garcia. I'm the policy and advocacy Director for Youth ALIVE!, based in Oakland, California, and my coworkers do the life saving work of being violence professional professionals. We go to the hospital bedside of folks who have just been violently injured, surviving a gunshot wound, stab wound, physical assault, and help them pick up the pieces in the aftermath of what might be the most traumatic moment of their life.

Through our advocacy, violence prevention professionals are considered community health workers, and looking at what other states have done to fund violence prevention through Medicaid is exactly what we want to have happen here in California. Unfortunately, at $26 an hour, it is maybe not worth the cost of us doing the administration to even draw those funds down.

That's why we stand with the other community health worker community across California and ask for an increase in the rates to ensure that we can actually respond to the demand for our services, which in places like Oakland is unfortunately far too high. Thank you.

Thank you.

Good afternoon, Madam Chair and Committee. My name is Jesse Tarango. I'm with Community Health Partnership, an association of 10 community health centers in Santa Clara and San Mateo county. In addition to running a CHW training program in Spanish this year, we are also one of the few CBOs that employs a CHW and places them in one of our health centers. It has been a challenge, to say the least, building the infrastructure to support this has been very difficult.

We're very grateful for the seed funding that we have from our local health plan and the support and technical assistance. But going into the future, the current reimbursement rate would not be enough to support what we're doing. We are also not living up to the full potential of the CHW as most of the work is done through telehealth, when in reality we would love to see our CHWs out in the community supporting community members where they're at.

We are in full support of raising the current reimbursement rate for CHW benefit services. Thank you.

Thank you.

Good afternoon. I'm Andrew Menor from Asian Resources, Inc. A nonprofit organization dedicated to supporting marginalized communities, especially Asian American, Native Hawaiian, and Pacific Islanders, or AANHPI's, both in SaC and across the state. Our CHWs provide crucial outreach, education, and navigation assistance ensuring access to essential services like healthcare and public benefits.

Our impact was demonstrated most markedly during the COVID-19 pandemic, when we led CHW initiatives with other AANHPI organizations in Los Angeles and Sacramento, providing vital COVID information and resources and navigation services that mitigated the effects of the pandemic and saved thousands of lives. These efforts highlight the indispensable role of CHWs in communities like ours. However, more support for CHWs is needed for them to address pressing and persisting health inequities beyond the pandemic.

To this end, we urge you to raise the Medi-Cal reimbursement rate for CHWs, ensuring that they can sustain their invaluable work and address our community's unique needs. Thank you.

Thank you.

Buenas tardes legisladores y legisladoras mi nombre es Irma Ramírez. Soy promotora comunitaria de visón y compromiso. Estoy aquí porque estoy preocupada como promotora y como persona acerca de los servicios porque nosotros sabemos que tenemos muchos servicios pero si no tenemos alguien que nos de adecuademte quien les haga llegar a las personas necesitadas no podrían llegar a ellos. Yo como promotora me preocupo porque lleguen los recursos a las personas ya que hablemos muchas personas con necesidades desde básicas de comida renta salud y en todos los aspectos visión y compromiso se ha preocupado mucho por tener familia sanas y darles una vida digna los recursos que ustedes ofrecen y que nosotros tenemos a a proveer para todas las personas necesidades hacemos que lleguen bajo nuestras manos y bajo nuestra educación. Esas personas que tienen necesidades si no fuera porque nosotros como promotoras damos ese servicio no tuvieran el acceso y ahorita estamos preocupados porque necesitamos más apoyo como promotoras porque también sabemos que los gastos que nosotros tenemos y los sueldos que nosotros tenemos no son suficientes pedimos su apoyo tanto para las organizaciones como para nosotros como como promotoras para tener una un salario justo y también para que se nos valore el trabajo que hacemos ya que sabemos que el trabajo de promotora es algo muy importante y yo estoy orgullosa de ser promotora y de poder ayudar a mi comunidad y de servir con amor y con corazón gracias.

Good afternoon. My name is Eric Arausa. I'm a first generation Latino incoming medical student and I speak on behalf of my community and all the on the shoulders of giants, really, I want to thank you all for being here and your time. And I want to express that community health workers play a vital role towards the continuity of care of our community, of our patients, of my family.

And I ask you to support increasing the wages of community health workers because, working closely as a medical assistant with providers, I see the need and the urgency for community health workers in a space where providers do want to do the work, but they simply don't have the time in 15 minutes when they're complicated with charting and other things that come from executives.

I urge you again to support the living wage, to bring about more community health workers in the community, and to increase the number of representation of Latinos in the space of blacks and other POC. Thank you.

Thank you.

Good afternoon. Richardson Davis here with the California Council of Community Behavioral Health Agencies. I'm just here to highlight the importance of community health workers and promotoras. I would like to align my comments with that of the other panelists today, highlighting the importance of the CHWs, and they just play such a critical role, hearing some of these stories today.

And also with the man who just was up here before me, I want to line my comments with him and want to concur with Dr. Ghaly's comments about workforce. Thank you.

Thank you.

Good afternoon. Matt Lege, on behalf of SEIU California, really appreciate the Committee pulling together. Both committees pulling together this incredible panel where we can really hear from the communities, want to appreciate and highlight how important community healthcare workers are to closing our health equity needs. So totally support that just as we're considering funding, really want to make sure that Committee is also considering and the Legislature is considering workforce standards.

I was really proud to hear about the investment that every single one of these folks are mentioning around, making sure it's a living wage. And we want to make sure that that is considered as funding potentially would be moved forward. And also considering, make sure that we want to make sure these workers are part of the care team and fully integrated. Thank you very much.

Good afternoon, Chair and Committee. My name is Josaline. I'm actually here from Butte County. I'm not representing my organization today at all. I'm actually taking my own personal time to be here because it's a very important matter to me. I ask, you know, as a receiving person from the services that CHW's provide.

And now being in the field, having in the last year, given the opportunity to actually train people coming into the field, I see the importance of continuing this work and the quality of services that are being provided by a diverse group of people throughout the state. From Butte County, I'm considered one of those desert areas that does not have the capacity building for continuing opening the door for community health workers.

So I really hope that you guys, I urge that this increase happens as it will continue to open the doors for those entering the field and just continue to support those that have already been working as community health workers over this last decade and even further than that. I really think it's such important work.

In the last year, again, as a community health worker, I've been able to give gifts to families in the holidays and remember the time where I was receiving those same gifts from another community health worker. So it's very important for me to just speak up and be able to advocate for those that weren't given the opportunity to be here. So I really thank you guys for your time and I hope that this impact that's being done here gets down to Butte County eventually as well. Thank you.

Thank you.

Good afternoon, Chair and Committee Members. My name is Alicia Crooks and I'm here today as a community program manager for Pear Suite. We're a digital platform dedicated to supporting billing to insurance payers for CHW work. We work with billing through insurance payers, but we work with small and large CBOs supporting their effort to build and keep financial infrastructure for their community health workers. I also represent the thousands of CHWs that are barely supporting themselves to actually live in California.

I'm just here to urge you to increase that Medi-Cal rate so that the workforce can actually thrive in the area that they work in, live and work in. Thank you.

Thank you.

Good afternoon, Chair and Committee Members. My name is Alma Monjaraz and I am with the Latino Coalition for a Healthy California. I've been working as a promotora for over 10 years and I serve the community of Fresno. I love the work that I do because it allows me to use my privilege of being bilingual, English and Spanish, and give my community, engage with them and help them out and give back to my community.

The CHWPRs play a critical role in the Latin community, acting as an interested voice to help allowing to bridge the gap between the community's needs and the healthcare system. We build the relationship and regain the community's trust in this system that has failed to include them and have broken their trust time after time. Being a promotora made me realize just how demanding this job is and how passionate you must be to do this.

Most of us start off as volunteers and stay because we love and we have a passion to do this despite the lack of appropriate compensation, which forces many of us to have full time jobs outside of this.

Thank you.

Buenas tardes presentas y miembros del comité mi nombre es María Monjaraz. Estoy con locución Latina por un California. Saludable he estado trabajando como promotora para el condado de ventura y sirva la comunidad del condado de ventura. Este amo lo que hago porque puedo ayudar a más familias como las mías y también puedo hacer el puente de recursos para otras familias que necesitan ayuda. Son las promotoras no solamente necesitan un salario mejor pero también necesitan un título formal y reconocidos por el trabajo que hacemos porque no solamente probemos los servicios a la comunidad pero también trabajamos fuera de esa burbuja de la de los servicios o barreras que nadie quiere hablar. Las promotoras hablan el mismo idioma y ayudan desde la experiencia y del conocimiento que han pasado. Son nosotros trabajamos con la realidad de las que muchas familias no de las que muchas personas no quieren hablar estamos quebrando barreras que están ayudando a las familias a poder entender el sistema y poder entender atender recursos que de los cuales. No saben no solamente somos ese puente para las familias pero también somos la voz somos la voz de inmigrantes de familias de bajos ingresos y también de trabajadores del campo. Necesitamos a California a incluir un aumento de la tarifa base para los para que la nueva tarifa de CHWPR sea 53.35 muchas gracias.

Gracias.

Good afternoon. My name is Mar Velez, Director of Policy with the Latino Coalition for Healthy California, born and raised in south central Los Angeles, proud former Oakland resident and here standing in solidarity with our CHWPRs, requesting that you all support a rate increase for our workers. Thank you so much.

Thank you.

Good afternoon, my name is April. I'm also here with Pear Suite, which is the digital platform. I just know that if we were to increase the CHW wage, that we would have more community based organizations, nonprofits and FQHCs that would be willing to work and provide jobs for the CHWs. Because right now, when they do cost analysis, they do not see a benefit and they base it on community health workers having to have a certain number for the caseload when the work that community health workers do shouldn't be based on a caseload, but the effectiveness of what they do and how they reach out to their community.

So I really do believe that this wage increase will bring that availability more jobs and more security for the community health workers and promotoras in their community. Thank you.

Thank you.

Good afternoon, Madam Chair and the Health Committee. My name is Carol West. I am a community health worker. I immigrated from South Africa, left everything behind, family and career, and really was the beneficiary of community health worker services. Later went to a community college and came off the production line in 2010 and looked for a job. And people said, oh yes, we have those, but they're volunteers.

So I'm here to tell you that there are people that do this job out of the passion from the bottom of their hearts and the colleagues that I graduated with. One woman in particular really put a fire in my belly. She landed up one morning with a tooth abscess, the community health worker. She also was working three jobs because her community health worker job didn't pay enough and she did not have health care to address her own personal health care needs.

So I'm here to ask you, please, to raise the rate to 87.5% of the Medicaid rate, which I believe is $53.35 per half hour. This will not be a cure all for everyone. We know that community based organizations, it is a challenge for them to draw down this money, but we are grateful for the benefit, but we do hope that you raise the rates.

Thank you. And our organization represents more than 1000 community health workers at this point in time.

Thank you. Creo que vamos a obtener la traducción de los comentarios en inglés si tenemos lo tienen por favor no pasa la ceniza the sergeant. Well, thank you so much. I want to sincerely thank you all for coming today to engage around this critical issue. We will be back here on Tuesday, March 19, for our first bill hearing. With that, this hearing is adjourned.