Assembly Budget Subcommittee No. 1 on Health and Human Services

Good afternoon. This is the Assembly Budget Subcommitee Number One on Health and human services. Today's hearing is our first regular sub one hearing covering health issues for the year. For those of you who already know, we've already had our first sub one human services hearing on February 22 of this year, followed by a joint informational hearing with the Health Committees on mental health on February 28. Today's hearing will be focused on public health and emergency medical services.

We are making one significant change to the agenda, which is to move several items to nondiscusion for these issues. There will be no presentation or discussions of the proposals as usual with nondiscusion items. We will welcome public comment on them at the end of the hearing, should there be any. The following issues will be moved to nondiscusion, issues 4, 16, 18, 19, and 24 through 30.

I also want to remind everyone that public comment on all issues on the agenda will be taken at the end of the hearing. After the last issue has been presented, we will first take public comment from individuals here in the hearing room, followed by public comment from individuals who are on the phone. The public comment call in number is on the subcommittee's website. It will also be on the live stream screen once public comment has started, and I will also share it right now.

The phone number is 877-692-8957 and the access code is 131-5126 with that, let us begin panel one with Dr. Tomas Aragon, director and state public health officer with the California Department of Public Health, who will be providing the annual State of public health. Dr. Aragon, before we begin, we will establish quorum.

[Roll Call]

When you're ready Dr. Aragon.

Thank you. Good afternoon, chair and members, I am Dr. Thomas Aragon, state public health officer and director of the California Department of Public Health. It's an honor to be here today to present on the State of Public Health in California.At CDPH, our mission is to advance the health and well being of California's diverse peoples and communities and the vision that all Californians enjoy healthy communities with thriving families and individuals. Health is not the absence of disease or injury.

It is a state of complete physical, mental, and social well being. The Institute of Medicine defined public health as what we as a society collectively do to assure the conditions in which people can be healthy. Public health is our collective endeavor to protect, promote, and improve the health of our communities. Unfortunately, the field of public health is often misunderstood and sometimes confused with health care, which is the provision of medical services. Here is the public health approach. It has four pillars.

First, ecological social, or eco social for short, the relationship of people with their family, neighborhood, and social networks and with their environment. In other words, health happens where people live, work, learn, play, and pray. Think of COVID-19 pandemic and its widespread impacts. Think of health impacts from climate change. The second pillar is life course and intergenerational processes. Think of adverse childhood experiences and toxic stress and the intergenerational transmission of the social and biological effects of adversity and trauma. Third, equity and health equity.

Think of low income communities and essential workers with higher rates of COVID-19 exposure, illness, hospitalization, and death. Think of disproportionate impacts of violence and mental illness on communities of color, especially Black African Americans. Fourth, prevention focus, especially primary prevention. Think of laws reducing availability of tobacco products and exposure to secondhand smoke. Think of smarter street design, vehicle standards, seatbelts, child safety seats, and robust safe mobility options to reduce road fatalities. Well, what have we accomplished?

Over the last 20 years, public health has contributed to significant improvement in health and well being of all groups in California. For example, the death rate for lung cancer has decreased by 57% since 2001 thanks to comprehensive tobacco control efforts creating a social and legal context in which tobacco is less desirable, acceptable, and accessible. The HIV death rate decreased by 71% between 2001 and 2021 for all groups and by 73% for Black individuals.

Birth rates among adolescents decreased by 78% between 2000 and 2020 due to improved access to public health prevention strategies, including comprehensive sexual health education, clinical services, and promotion of healthy relationships and communication practices. Despite declines in mortality for all groups in California, significant racial and ethnic health disparities continue. For example, overall life expectancy is 10 to 12 years less for Black individuals compared to the group with the highest life expectancy, which is Asians.

The rate for alcohol related deaths is 14 times higher for American Indian and Alaskan Native individuals compared to Asian individuals and is the fourth leading cause of death for this group. The pregnancy associated mortality rate is 3.5 times higher among Black women than among white women. The HIV STD death rate is 11 times higher for Black individuals than Asian individuals.

Public health works to reduce these disparities by informing policies that address the underlying social, environmental, and behavioral drivers of health and by regulating selected sectors with high impacts on health. For example, we license, certify, and inspect over 12,000 health facilities across the state. Equity is a foundational, guiding principle in public health. Based on their needs, every Californian should have the resources and opportunities to be healthy and to thrive. This requires prioritizing investments in communities with continuing health inequities.

Today, California faces some of the toughest public health challenges in decades. These challenges include COVID-19, chronic diseases like cardiovascular disease and Alzheimer's disease, mental illness and substance use disorder, firearm related death and injury, and health impacts from climate change. CDPH is building capacity to tackle these public health priorities. Climate change is a major force impacting the public's health, affecting all aspects of our health and well being across, affecting access to clean air, water, food, shelter and physical safety.

Heat waves, droughts, wildfires and wildfire smoke floods result in illnesses, injuries and deaths as well as loss of livelihoods contributing to unemployment, poverty and housing instability. Direct and indirect effects increase chronic and infectious diseases, mental health challenges, and heat and smoke related illnesses. The impacts have the greatest toll on the health of those who are already experiencing health, social and economic inequities.

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

Millions more experienced severe illness, hospitalization, disruption to education and work, sometimes loss of jobs or housing. COVID-19 highlighted and exacerbated existing health inequities. COVID-19 death rate was significantly higher for Native Hawaiians and Pacific Islanders, Blacks and Latinos compared to the overall state rate. Low income communities suffered disproportionately. They live in crowded conditions, work in essential frontline jobs, and had more exposure to COVID-19 they had less access to resources, creating gaps in healthcare information, housing and economic security.

Through our collective actions providing testing, vaccination, treatment and public health guidance cases, hospitalizations and deaths dropped significantly between 2020 and 2021. In 2022, COVID-19 dropped to the third leading cause of death. Now, in 2023, we have reached the lowest levels since the pre pandemic period, enabling activities of daily life to resume more safely. COVID-19 will remain with us for the foreseeable future, including the uncertain burden of long COVID.

Using lessons learned from the pandemic, the California Smarter Plan enables us to manage COVID-19 today and prepare for future surges and variants, as well as respond to emerging infectious diseases. Last year, CDPH leveraged COVID response infrastructure and the smarter plan to respond to the mpox outbreak. We were able to activate systems for surveillance, vaccination, and treatment to highly impacted communities. 14 day average case rates have fallen from more than 90 per day in August 2022 to less than one case per day now.

CDPH distributed vaccines and antiviral treatments statewide, supported vaccination events, and provided disease prevention messages. Over 300,000 vaccine doses have been administered to more than 180,000 people, with over 116,000 persons receiving two doses. Again, at the end of 2022, we leveraged our COVID response infrastructure to address the simultaneous surge of COVID-19, Influenza, and RSV. We tracked disease levels and the real time and projected impacts on the healthcare system.

CDPH provided data to local partners and policymakers to guide the response to this triple-demic. The governor's 2023 budget proposal continues investments to support the state's effort to protect against COVID-19 and other public health threats. California's population is growing older. By 2031 in four, Californians will be over the age of 60. Ischemic heart disease and Alzheimer's disease continue to be the top leading causes of death for Californians. Cardiovascular disease contributed to the most deaths in 2021.

This condition group includes ischemic heart disease, stroke, hypertensive heart disease, all of which are the top five leading causes of death. During the pandemic period, rates of ischemic heart disease increased, countering a long term trend of decline. From 2021, the data shows that we've had a little bit of a turndown in that trend, returning to prior trends, which is good. Most cardiovascular diseases can be prevented by addressing behavioral risk factors such as tobacco use, unhealthy diet and obesity physical inactivity harmful alcohol consumption.

However, recognizing that deeply rooted social and economic inequities are the drivers of many health behaviors, public health informs policies that improve community conditions so all people can enjoy safe, walkable neighborhoods and access to healthy foods and affordable housing. Deaths from Alzheimer's disease have more than doubled since 2000, and about one in 10 adults in California experience subjective cognitive decline or memory loss.

CDPH collaborates with stakeholders to support the master plan for aging, to prevent and prepare for the growing number of Alzheimer's cases, and forge a path forward. Several conditions other than COVID-19 show substantial increases in death rates over the past two years. These include deaths related to alcohol, road injury, and drug overdose. Drug overdose has by far caused the largest increase, with deaths increasing by over 200% between 2011 and 2021. This began with a 63% increase in the pre-pandemic period.

This increase surged dramatically during the pandemic period, with an additional 79% increase in just two years and over 10,000 deaths in 2021. In 2019, drug overdose deaths overtook ischemic heart disease as the top cause of years of life lost. Between 2019 and 2021, there was also a 38% increase in homicides after many years of decreasing or level rates. This was primarily driven by an increase in firearm related homicides.

Exposure to gun violence traumatizes survivors and communities, impacting mental health and social well being many public health challenges start in early life among children, youth and young adults, impacting their life course, trajectory of physical, mental and emotional health, and well being. Children and youth are dealing with unprecedented challenges due to COVID-19 pandemic.

As of September 2022, almost 38,000 of California's children under 18 had lost a parent or caregiver due to COVID-19. This type of loss has long term health consequences and contributes to adverse childhood experiences or ACEs. Toxic stress over time from ACEs can alter brain development and affect our body's responses to stress. ACEs are linked to chronic health problems, mental health issues, and substance misuse in adulthood. In California, about six in 10 adults experience at least one ACE before the age of 18.

Public health works with the Department of Social Services and the Office of the Surgeon General to promote policies that prevent ACEs and build safe, stable, nurturing relationships and environments through programs like home visiting. Mental health conditions affect more than half of us people over their lifetime and contribute to worse overall health and risk of death by suicide.

In California, severe mental illness and substance use disorders have a significant impact on young adults, with mood disorders and schizophrenia as the first and third leading cause of hospitalizations, respectively for Californians ages 15 to 24.

Mental health conditions are the second leading cause of years lived with disability for Californians and the leading cause for children between the ages of 5 to 14, emphasizing the need to strengthen prevention, early identification, and compassionate care. Untreated mental health problems or substance use and addiction can result in injury and premature death. In 2021, over 4000 Californians died by suicide. The overall number of suicide deaths has decreased since 2018 because of the decreases in older persons.

In contrast, suicide and self harm are among the top five causes of death for 15 to 44 year olds, and rates have been rising in recent years among Blacks and Latino Californians. Hospitalizations and emergency department visits for mental health related conditions are higher among black individuals than for any other race or ethnic group. Among ages 15 to 24, mood disorders is the leading cause of hospitalization I've already mentioned that point earlier.

The governor's proposed budget demonstrates steadfast commitment to advancing the health and well being of all California's communities while prioritizing the most vulnerable through critical investments in the behavioral health system, social safety net system, and public health infrastructure. Recent public health efforts aim to prevent addiction and overdose through harm reduction strategies, public awareness, education, recovery, and support services, as well as innovative approaches to make naloxone and fentanyl test strips widely available.

The California Youth Behavioral Health Initiative, an interdepartmental collaborative effort to transform the behavioral health system to be responsive to the current needs of youth and children. CDPH is leading an educational campaign to normalize seeking support for mental health challenges and to destigmatize behavioral health in communities. The budget provides for core public health infrastructure. Through the future of public health initiative, the state invested $300 million to modernize state and local public health infrastructure and transition to a more resilient system.

Centered on equity, we are building our capacity and capabilities in long term strategic planning and policy development, workforce development, data modernization, data science and decision intelligence, emergency preparedness and response healthcare partnerships to improve population health management, community engagement and partnerships, and recruitment and retention of a diverse workforce that reflects the communities we serve. This funding is already at work with many new staff hired across the state to support this transformation.

CDPH is an agency with over 220 programs and over 4000 staff, but public health is what we do collectively to ensure the conditions in which every Californian can be healthy and thrive. Thank you for your leadership and support.

Thank you, Dr. Aragon, for that annual state of the state on public health. I will now bring it up to the dais and see if there are any Members who have questions. Dr. Jackson.

Thank you very much. And thank you very much for the report. I mean clearly, there are a lot of red flags when it comes to the State of our public health here in California. My first question is, of course, we've dealt with a pandemic and of course monkeypox as well. Should California begin to see pandemics or other public health emergencies happen more often in California?

Yeah, so the process of really pandemic, it's really a global process just with the growing population and encroachment to areas where viruses live. Because they're usually zoonotic, they come from animals most often. So there's always introduction of viruses into the human population. So unfortunately, the answer is yes.

And because we should be expecting more public health emergencies over time. Obviously we identified many gaps during COVID-19 in terms of not only public health. But how we organize ourselves as a society. What are some weakness and gaps that we saw in COVID that still exist today that you think we really need to make sure that we address before the next one comes?

I would say the primary gap we had was the existing health inequities that we had before the pandemic. Because when the virus came, the people who were the most impacted were those that lived in crowded housing and had underlying chronic conditions, had limited access to health care. So those existing inequities were amplified by the pandemic. It just really revealed what already existed. So we really need to do a lot more there.

And then from a public health perspective, we need to continue our investments in emergency preparedness. I've been in public health long enough to see the waxing and waning of investments for public health preparedness. And so we have to just continue to make sure when things calm down, people sort of lose interest in preparedness. It's really important to continue them.

And obviously, when you talk about the rise, of course, COVID loved diabetes. COVID loved hypertension, high blood pressure. Right. All those things. All those things are personal behaviors that you've outlined in this report. What can we do better to make sure that people are, that some of these trends go into the opposite direction?

So you can see we made, for example, progress in tobacco, which is a personal behavior, but it's really driven by the social environment that you find yourself. So if you have easy access, if you were to see advertisement for tobacco, we systematically dealt with tobacco in such a way that we reduced the demand, and smoking went down dramatically.

So, although ultimately, it does seem like it's a personal behavior, it's really driven by social norms, and the social norms in the environment are the ones that we shape and build. And so there's a saying that we have make the healthy choice the easy choice. And so that really comes from us working on systems, policies, and the environment to make the healthy choice the easy choice for people feeling free to exercise in your community, for example.

So tobacco is one of those things that was very prevalent at 1.0. Right. But we continue to see some decreases. Correct. What is the next thing we should be going after?

So there's a different thing.

And I do that while I'm drinking my soda.

First thing I noticed when I walked in the room.

I didn't say there was an hypocrisy involved in these questions.

I would say the approach that HHS is taking, which is a very holistic approach, taking a life course and intergenerational generational approach, really focusing on early life events and stresses that really cause the trajectory for a lot of the things that we're seeing. So we know, for example, early life trauma impacts your brain, your body, and your behaviors for the rest of your life.

So a lot of these things that we're seeing are really exposures that happen early on in the community where people are more vulnerable, especially when they're young. So I would say that the whole area of behavioral health and mental health is really the frontier for public health. Oftentimes. Historically, we've divided physical and mental when it really is one, and it really starts. Health is produced in the community, and we have to figure out how to support that process in the community.

So do you support universal screenings for children for ACEs?

Absolutely. Yes. I should tell you that my wife is a first grade teacher for almost 30 years, and I can tell you that she sees the effects of adversity at early ages because they come unprepared to learn, and they have to learn a lot of the skills early on. So, yes, screen is absolutely important, not just in the healthcare setting, but also in schools and other settings where we're touching kids when they're young.

And then finally, my last, you know, do you believe that California is in a mental health?

Look, I would say the United States is in a mental health crisis. This is a problem, really, across the United States, looking at the data, and, yes, I would say we are in a crisis, just given the numbers that we're at, these are early indicators. We see trends going up. I think we have to treat it like a crisis and really be focused. And I think we are focused not within DPH, but within the HHS agency. There's a lot of investment and focus on this area.

And then finally, do you believe that racism is a public health crisis?

I believe that racism is an ongoing crisis that we've had. It's one of these things where I think sometimes people feel like, oh, things have gotten better, but they have in some aspects. We can see this right now in the United States when we see the blatant discrimination against people of color. So I would say, yes, we do have a crisis that we have to continue to address.

So for us, equity is a core principle in what we do, and we're on that journey to really transform our systems to systematically address discrimination, racism, and equity for all equity issues across other dimensions of discrimination.

Thank you very much, Mr. Chair.

Bring it back up to the chair. I'm going to follow up first. I want to appreciate the improvements we've made over the last several decades. Primarily, I wanted to call out, if I could, the birth rates among adolescents that have decreased by 78% in the last two decades. Coming from one of those communities where we had high teen pregnancies. It has been public health strategies that have made significant improvements in communities like mine.

But I'd like to drill into some of the areas over the last couple of years where we seem to have struggled. You identified that it was alcohol, road injury and drug overdoses that have increased 200% in the last decade. But specifically, you said that it increased 79% in just two years and now has over 10,000 deaths, which were reported in 2021. So I'm wondering how you can help to frame it in the same way you just described.

How do we make the healthy choice, the easy choice here? How do we address many of the alcohol road injuries and drug overdoses that we're seeing?

Yeah, that's an incredibly good question. And each of them are very different. And I'll just start with just drug overdose. If you have been following the opioid overdose epidemics, there really have been different errors. We saw the error with primarily prescription drugs, then heroin. We're seeing now fentanyl. And fentanyl ends up in not just opiates, opioid drugs, but they end up in other drugs. So you might be thinking you're taking a Xanax pill and it may contain fentanyl, and this has really transformed.

It's made it much more difficult if you put on your COVID lenses. It's almost as if the epidemic, just like the variants, have evolved, the epidemic has evolved to higher potency. Opioid drugs that are incredibly addictive and also deadly. And so then our strategies really have to change. And so it's not just a matter of having the early life events are important, but also you have these events where you're at risk for overdose.

So you have to have the ability to, if you think you might have fentanyl to be able to test for it, have naloxone available. So having those systems in place are really critical, and then having access to treatment. So people have to be able to have early, easy access to treatment for opioid addiction. And so those are areas that agency is working on to address.

Having young children. It's something that keeps me up late at night, is thinking about the amount of fentanyl overdoses that we're seeing in communities all over our state. On the next topic I'd like to address is Californians who died by suicide. In your report, you highlighted both young black and Latino Californians, but the CDC has also added both female and LGBTQ youth as being disaggregated and at particular risk.

And I'm wondering if you can comment if California is seeing that same data.

I would have to look at the data again. I'll have to follow up on that.

Finally, if I can, just representing the community that I do, was hoping you could comment regarding syphilis. As Fresno county has the highest congenital syphilis in our state, I'm wondering if you can comment on specific strategies that may help us to address that.

Yeah. And the problem with congenital syphilis in that population. It's a complex social problem. We have sort of the combination of poverty, drugs, sex for drugs and other services sort of really causing people not to be diagnosed and becoming pregnant and then not having prenatal care and then of course, delivering a child with congenital syphilis. So this is really an important problem. We do have our staff specifically focusing on that.

I don't have the details with me at the moment, but I can make sure that we put that together for you and provide it.

Appreciate that. And didn't expect you to have all 4000 employees ready or the 220 programs.

But it's a problem that we are focused on for the reasons that I just mentioned.

With that would like to thank very much, Dr. Aragon, and we will now move on to issue two.

Okay, thank you.

Our second issue is on the emergency medical services data resources system budget change proposal. We will have two presenters on this panel. First, we will begin with Lorna Eby, Deputy Director for the Project Management Division in the Office of Systems Integration, and Rick Trussell, Chief of Administrative with EMSA. May we begin with Ms. Eby?

Okay. Good afternoon, Mr. Chair and honorable committee members. Thank you for having me here today. The Office of Systems Integration is requesting 1.13 million in fiscal year 23-24 expenditure authority for six limited-term positions to provide project management, fiscal, and procurement services to the Emergency Medical Services Authority in support of the California EMS Data Resource System project known as CDRS. The proposed CDRS project is intended to create links between various health information exchange systems to increase data interoperability between hospitals, EMS agencies, and healthcare organizations.

CDRS is envisioned to provide a solution that will allow for the aggregation and analysis of EMS data to ensure that patients receive the appropriate care by qualified EMS professionals and house a data repository for information on all EMS transport within California. This is needed to drive quality assurance to ensure that California EMS is aligned with national standards and best practices and allow for better informed and data-driven policy decisions.

The Cedars project is currently in stage two alternatives, analysis of the California Department of Technology project approval lifecycle, or PAL, process. The PAL process is currently targeted for completion in June 2024. The OSI resources requested will ensure all stages of the PAL process are managed consistent with project management and procurement best practices and within a collaborative and transparent governance framework to ensure inclusion of stakeholder groups to achieve the envisioned goals, objectives, and outcomes. And I will take a pause there for any questions. Mr. Chair.

Mr. Trussell?

Yes, sir. Good afternoon, Mr. Chair and members of the committee. I'm Richard Trussell, Chief of Administration at the EMS authority, which we'll refer to as EMSA. As requested, we'll provide a brief overview of EMSA's proposed budget and the two specific trailer bill proposals currently under consideration by the committee. The Governor's Budget for fiscal year 23-24 includes. Am I missing something?

I believe you're on issue three if you can speak to issue two.

Issue three is the oversight of the budget, correct?

Yes, but we're still on issue two.

Oh, I have no comments on that.

Okay. Nina Hoang with the Department of Finance.

Department of Finance, Nina Hoang. No further comments.

LAO?

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

Thank you. We will bring it up to the dais to see if there are any members' questions. Seeing none, thank you very much and move now on to issue three.

My apologies. The Governor's Budget for fiscal year 23-24 includes expenditure authority in the amount of 53.7 million and 114 permanent positions. This is a reduction of approximately 121,000,000 over last year's budget and is primarily the result of a reduction of 100 million in reimbursement authority and $21 million in various one-time appropriations. Of the 53.7 million, 30.5 million, or 57%, is delegated to state operations and 23.2 million, or 43%, to local assistance.

State operations funding of 30.5 million is 54% General Fund, 18% special Fund, 16% reimbursements, and 12% federal. Local assistance funding of 23.2 million is 48% reimbursements, 48% General Fund, 3% federal and 1% special funds. Issue number five if there are no questions, I'll move on to issue number five.

Let's stay on issue three if we can. We will now go to Shelina Noorali with the Department of Finance.

Shelina Noorali, Department of Finance nothing further to add.

LAO.

Will Owens, LAO, nothing further.

We will now bring it up to the dais to see if there are any members' questions. Seeing none, we will now move on to issue five.

Issue number five is the California Pulse E Registry Act trailer bill language. EMSA is proposing to strike through the statutory requirements to integrate the advanced Healthcare Directive registry into the e-pulse registry. The pulse form is a medical order signed by both a patient and physician, nurse practitioner or physician's assistant that gives seriously ill patients more control over their care by specifying the type of medical treatment they wish to receive towards the end of life.

Chapter 143 statutes of 2021 Assembly Bill 133 enacted the California Pulse E-registry Act on July 27, 2021 which requires EMSA to establish a statewide electronic pulse registry system for the purpose of collecting patient pulse information and providing real-time electronic access to the form by EMS and medical providers. AB 133 also requires EMSA to incorporate the HCD registry, established pursuant to part five of division 47 of the probate code and overseen by the Secretary of State, into the e-pulse registry.

Existing law requires EMSA to incorporate the advanced healthcare directory into EMSA's physician orders for life-sustaining treatment registry. As there is no existing electronic registry for the HCD, integration of this data into EMSA's electronic registry is not feasible without significant delays to the implementation of the pulse e-registry and additional resources. Eliminating the requirement for EMSA to incorporate the HCD registry into the pulse e-registry will allow the pulse e-registry to be implemented in a timely manner.

Department of Finance

Shelina Noorali, Department of Finance nothing further to add.

LAO?

We have no concerns with this proposal.

We'll bring it up to the dais to see if there are any members' questions. I will keep it here at the Chair if I can. I'm going to drill in a little bit into this one. I'd like to understand how many forms the HCD registry currently contain and how much resources would be needed to convert them over to electronic forms.

Based on our early discussions with the Secretary of State, there's approximately 10,000 forms that they have on file there. Currently, we are currently estimating the resources needed to make that transition of those forms to electronic and we need to do further discovery on that process.

Does it not create confusion to have two separate registries and potentially lead to providers referring to outdated documents?

Well, EMSA's position right now is that it creates no more confusion than already exists today with the difference between the two forms.

I will say as one of those frontline providers, there is significant confusion, which is why I believe it was important for us to create a registry in the first place.

And I guess what I'm trying to understand is I don't want to delay the pulse e-registry from getting online as quickly as possible, but would like us to consider how we can also create an electronic registry eventually for HCD and would like to be able to work with the Administration to figure out how long and how expensive that would be. Would you be amenable or supportive to following up on that information?

Yes, EMSA would be amenable to following up on that information.

With that, we will. Dr. Jackson?

Well, no, my only concern was it seemed as though we were making this change, the statutory change, indefinitely. Like, there didn't seem like there was a timeline in which. Okay, if you need to do this for the post, then by what time do we expect the law to come back into effect so that we can still finish the job and by when do we see us doing so?

Well, currently we are in the discovery phase of that process and right now we do not have a definitive date, but we can get back to you when that process is complete.

Yeah, I would just hate to support this. And then now we forget all about it because we have 1000 issues that we have to deal with at this current proposal I wouldn't be in support of this. I think that we need to have just more of a long-term plan so we can understand how we can get both done right. And so looking forward to more discussion on that. Thank you.

Thank you.

The third, staff question within the agenda regarding amending the law to state that the integration of the two registries shall occur when resources become available, will most likely be the direction that this committee takes and would like to be able to work with the Administration to figure out the cost and timeline. Assemblymember Rubio.

Just to add to Dr. Jackson's comments, we're used to getting that standard answer. We're working on it. And quite frankly, you know, obviously, it has to be really frustrating for you as well as for us to keep getting the same answer over and over. You know, I do would suggest that to Dr. Jackson and Dr. Arambula's point that we have some definitive answers, because the fact that we come in and ask these questions is like, oh, we're working on it. What does that mean?

Are you working on it one day a week? Are you working on it one day a month? One day a year? It's a big difference to say I'm working on it. And then again, and one day a week versus one day a year is a huge difference. So if we can get a little bit more specific as to what I'm working or we're working on, it means.

Okay, understood. Thank you.

We will thank very much this panel, and we will now move on to issue six.

My name is Shelina Noorali and I'm with the Department of Finance and we'll be presenting on this issue. The Emergency Medical Services Authority proposes to remove the Medical Doctor requirement as a part of the eligibility criteria to serve as the department's Director and have a Chief Medical Officer of the department who shall be appointed by the Governor. Existing law requires EMSA's Director to be a licensed physician and surgeon with substantial experience in the practice of emergency medicine.

These requirements have limited the eligible candidate pool and made it more challenging to recruit for this role in the past. Therefore, removing the MD requirement for EMSA's Director will assist the department with tapping into a broader candidate pool while at the same time focusing on the appropriate skill set regarding public administration. Unless there are any questions, I will now address the questions included in the agenda.

Address the questions that are in the agenda, please.

The first is regarding the need for additional funding. The Administration is evaluating the need for additional funding, and any requests for additional funding will be submitted through the spring budget process. Second, regarding any concerns recruiting a Chief Medical Officer, it has historically been challenging to recruit an MD with experience in emergency medicine and skill set to lead a state department.

Therefore, the Administration believes that with both an EMSA Director and Chief Medical Officer, we will be able to recruit from a broader candidate pool and recruit individuals with the necessary skill sets critical to overseeing the department.

LAO?

We have no concerns with this proposal.

Bring it up to the dais for any members' questions. Seeing none. Assemblymember Alanis.

Just real quick, why is this a trailer bill and not a policy bill?

We believe that this is a trailer bill in order to advance discussions, but I would have to defer to the department on why this was introduced as a trailer bill.

I think we have to hit the button. It should be active now.

There we go. Sonal Patel, Department of Finance. I would also note given question one regarding a budget proposal. One of the outstanding questions was whether there would be a resource need associated with this request. Hence the submission of a trailer bill instead of a policy bill.

We will thank very much this panel. We will now move on to issue seven in the Department of Public Health. Thank you.

Issue seven is an overview of the California Department of Public Health budget being presented by Brandon Nunes, Chief Deputy Director of operations at CDPH. Mr. Nunes.

Thank you, Chair and members Brandon Nunes, Chief Deputy for operations at the Department. Is that better? Perfect. The agenda does a really good job of providing the overview of our budget. So I'll kind of hit some highlights and then we have members of our team to discuss some of the other issues that are in the agenda today. But as far as overviews goes for 23-24 our Department has a budget of 5.5 billion and that's going to support our six centers and various divisions and offices.

Broken down, we have about $1.0 billion coming to us from General Fund, roughly 2.2 billion coming to us in federal funds, and then 2.3 billion coming to us in the form of roughly 50 different special funds. That's also broken down by 2 billion for our state op support, as well as three and a half billion that goes for local assistance for our local health jurisdictions and other local assistance programs.

The agenda points out that there is a decrease of our budget between 22-23 and 23-24 of roughly 1.4 billion, or 20%. I just wanted to highlight real quickly that this isn't the result of budget reductions or anything like that. It's primarily the result of one time funding that was provided in 22-23 that was naturally going to fall off in 23-24. The largest of this, as you may all recall, COVID support that was provided in the 22-23 budget of roughly 1.7 billion.

That number now for 23-24 is roughly 176,000,000. That's spread over about 100 million for our COVID response support, as well as about 75 for our new smarter plan initiative. There was also, you may recall, in 22-23 a number of different General Fund investments that were meant to be one time. Your agenda on page 25, I believe, does a really good job of inventorying what those one time General Fund items are for. And that's primarily the change for our General Fund, is those one times.

We're happy to say that the investment for the future of public health, as Dr. Aragon mentioned, of 300 million remains in the budget, roughly 100 million coming to our department, and 200 million going to our local health jurisdictions. We do have some issues in our budget related to the administration's proposal to address the budget gap, primarily in two areas. The first is related to our public health workforce. We had some investments that were made last year.

And there's roughly a $50 million reduction to public health workforce for things such as training, workforce development and the like of about 50 million. And that reduction spread over a four year period, roughly 5 million in current year and roughly 21 million in budget year and budget year plus one, and then balanced by a few million in the budget year plus two. We also have an issue related to our climate and health resilience planning reduction that was put in last year's budget.

The difference with this particular reduction is this is one of the administration's trigger reductions. So to the extent we are building the 24 budget and there is funding that's available in January 24, this would be a trigger reduction that would be restored. And then finally, over the course of our hearings, there's going to be a number of different investments that we talked to you about. There's roughly 14 million that's included in our budget related to about 15 pieces of legislation that passed last year.

We have about a 3.2 million augmentation from our tobacco tax revenues from Prop 56 and 99 that are going to support our tobacco cessation programs. And then finally we have about a $200 million increase in the current year and about a $240 million increase in budget year to support our public assistance programs such as our women, infants and children AIDS Drug Assistance program and our genetic disease screening program. That's a high level summary. We, of course, have our team to discuss the number of issues that are in the budget, but that's kind of a high level for us.

Department of Finance.

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

LAO

Will Owens, LAO. Nothing further to add.

We'll bring it up to the dais to see if there were any questions. We'll hold the questions regarding the public health workforce until issue 12. We'll thank very much this panel and we'll now move on to issue eight. Thank you. Issue 8 and 9 are very closely related, so if you can please present them together. Issue eight is an overview of the budget adjustments to funding for the state's response to COVID, and issue nine is the COVID budget change proposal for 23-24. Melissa Reyes is the assistant Deputy Director of the emergency Preparedness office at CDPH. Can you please begin?

Good afternoon, chair and members. Thank you for having me here today. I'll start with a brief overview of the budget adjustments and then respond to the questions. The California Department of Public Health has received a budget adjustment reflecting a reduction of $614,000,000 for COVID-19 response activities. In the current state fiscal year 22-23. CDPH plans to reduce spending in many areas of the COVID-19 response, including public testing activities, therapeutics, and state operations support.

Additionally, CDPH no longer anticipates utilizing the $250,000,000 emergency contingency fund that was authorized for spending in 22-23, and now I'll provide an update of what COVID-19 looks like. Currently in California, the COVID case average and case rates have been plateauing over the last few weeks. Hospitalizations and COVID related emergency Department visits are also plateauing. Deaths are decreasing and remain low. However, there is a lag of about four weeks for deaths.

The overall hospital burden of COVID-19 and flu during the past winter has been similar to a serious flu season, such as the last severe one that we had in 2017 and 18. CDPH will continue to monitor cases and hospitalizations and is working with federal and local partners to shift surveillance strategies to improve our overall respiratory surveillance, including flu, RSB, and COVID-19.

CDPH will continue to distribute test kits as needed for outbreaks in high risk settings, continue allocating and distributing vaccines, therapeutics, and PPE, and maintain situational awareness and provide technical assistance to our local partners. Public health will focus on at risk populations while many services will transition to the healthcare delivery system. And we'll continue to aim to provide a safety net for Un- and Underinsured like we do with many other diseases.

And now I'll go into the areas that we're reducing for the current year, we plan to reduce testing by approximately $200 million through transitioning the state laboratory testing network that provides PCR testing to antigen testing by the end of the first quarter in 2023. Purchases of antigen test kits will decrease from $5 million per month to approximately $3 million. We are also able to order test kits from the CDC for free. State supported mobile endtoend testing sites at schools are ramping down and will stop by the end of the current year. There will be a reduction in therapeutics by approximately $40 million, primarily in reducing safety net grants by about 50% to 60%. The therapeutics media campaign will decrease by 75%, which is 27 million down to 7 million, and access to a telehealth vendor for those most disconnected to healthcare will be reduced by 75%, from 8 million down to 2 million.

Distribution of oral antivirals allocated to California from the Federal Government will continue until products go to commercialization. And regarding case investigation, contact tracing, and exposure notification, the California notify system will reduce activities to those supported by General funds appropriated in the current year. The number of COVID-19 communicable disease case investigators will decrease, as well as the number of staff who provide training, evaluation, and technical assistance for case investigation to state and local staff.

Most of the ongoing activities in this area are supported by federal funds through June of 2024. And moving into vaccinations. The staffing support for vaccinations is being reduced and resources will be prioritized for fall efforts and supplemented with federal immunization funding. Pop up clinics are being reduced this spring and fall, and resources will be prioritized for fall efforts and equity approach to reduce disparity gaps, including augmentation of backtoschool clinics and fall boosters for flu and COVID-19. California will continue to collect data on administered vaccinations.

Data quality efforts will continue but with reduced staffing. Western State's scientific Safety Review workgroup has concluded, and we will continue to follow CDC FDA Advisory group recommendations as we did prior to the pandemic and distribution of COVID vaccines to providers enrolled in MyCalvax will continue until commercialization, and resources will support ongoing efforts to increase access to vaccines for children and vaccines for adults resources. And finally, with state operations, funding for the public call center will be reduced. The overall state operation support will scale down.

However, we will continue our warehousing operations to distribute test kits and other medical countermeasures. Now for question two regarding vaccination rates for patients and staff at skilled nursing facilities. Ongoing data on COVID-19 vaccination coverage is reported by California SNFs to the Center for Medicare and Medicaid, and as of February 29, 2023 88% of residents in California SNFs have received their primary series 58% have received at least one booster dose, 95% of staff in California SNFs have received their primary series, while 45% have received at least one booster dose. CDPH continues to conduct outreach, share updated information, and provide technical assistance to SNFs and other state and local partners to ensure access to COVID-19 vaccine.

As an example, CDPH produced toolkits and other materials specifically for SNFs. And finally, for question three, populations at highest risk of severe disease and or hospitalization continue to be the elderly, those with immunocompromise, those with underlying medical conditions, and we continue to see equity disparities in our communities of color. Treatment can greatly reduce the risk of hospitalization for these vulnerable populations, which is why we launched our treatment campaign and continue to resource telehealth treatment access and are working with healthcare systems to improve treatment utilization.

Department of Finance

Shelina Noorali, Department of Finance nothing further to add.

Will Owens, LAO. We have no concerns with the 22-23 budget adjustments.

Bring it up to the dais for any members questions. Seeing none, I will keep it with the chair just for a second. Am I right that you stated that there were no contingency funds used out of the 250,000,000 in last year's budget?

That's correct.

And yet we're asking for another 50 million in this year's budget despite it being a tough budget year.

That's correct. Just in the event that things should progress with COVID that we were not expecting, so it may or may not be used.

We will highlight a $50 million reduction that came within public health workforce within issue number 12 that many of us have concerns about and will point to the fact that these contingency funds were not used in the past. We'll ask Department of Finance what happens to those contingency funds that were appropriated to public health. Those $250,000,000?

The 250,000,000 will revert back to the General Fund.

With that, I will thank very much this panel. We will now move on to issue 10. Issue 10 is the COVID-19 website transition and information technology resources BCP. We will begin with John Roussel, who is the Deputy Director for information technology services division at the CDPH. Welcome and please begin.

Thank you, Mr. Chair. CDPH launched a comprehensive, user friendly COVID-19 website and to provide the public service announcements steps people can take to stay healthy, resources available to Californians impacted by the outbreak, and data and NLH dashboards to boost COVID-19 awareness. The creation and maintenance of the COVID-19 website was a direct request from the governor during the pandemic. The site was developed in partnership with the California Department of Technology and the Office of Data and Innovation, who built and hosted the site.

In April 2022, the Department of Technology requested CDPH to take ownership of the site. CDPH has since taken ownership. We are asking for three limited term positions and 900,000 annually for fiscal year 23-24, 24-25 and 25-26 which includes licensing and operating costs.

Department of Finance Shlena Noorali nothing further to add.

LAO, we have no concerns with this proposal.

Bring it up to the dais for any members questions. Seeing none, we will thank you and move on to issue 11. Issue 11 is the maintenance and operations of the infectious disease data system for the smarter plan implementation BCP. James Watt is the assistant Deputy Director of the Center for Infectious Disease at CDPH and is testifying remotely. Can we welcome you and will you please begin?

Good afternoon, Mr. Chairman and members. Thank you very much. Can you hear me all right?

We can hear you, but we can't see, there you are. Please begin.

Great. Thank you very much. My name is Dr. James Watt. I'm an assistant Deputy Director in the Center for Infectious Diseases at the California Department of Public Health. CDPH requests $74.4 million in General Fund in 2023 and 24 for the maintenance and operations of critical infectious disease data systems established during the COVID-19 pandemic. These systems will continue to support the state's emergency preparedness and response efforts, disease control work for COVID-19 and disease control work for other infectious diseases.

This funding will support maintenance and operations of two important systems, the California COVID Reporting system, or CCRS, which has been renamed Sapphire and CalConnect, the state system for disease investigation and contact tracing, as well as IT infrastructure and security costs. And I will briefly describe those three items. First, CDPH requests $30.9 million in 2023-24 for maintenance and operations of Sapphire, which stands for the surveillance and public Health Information reporting and exchange.

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

Sapphire provides efficient and consistent flow of electronic messages to CDPH, and in addition, these resources will support integration and critical data exchange between Sapphire and other core CDPH systems, including Cal ready and Cal connect. CDPH received an appropriation of $26.3 million in 22-23 to provide MNO for one year to support and operate the system. This one year funding strategy was designed to allow CDPH to obtain updated MNO costs through a recompetition for the system.

In 2022, CDPH engaged in a new challenge based procurement process, resulting in a contract with a new vendor. A transition between the old and new vendor was completed by December 31, and we are now requesting maintenance and operations funding for 2023-24. As part of the transition, the system was renamed Sapphire to recognize that it receives data for all reportable conditions, not just COVID-19 secondly, CDPH requests $39.7 million for 22-23-24 for maintenance and operations of Cal Connect.

CalConnect is California's system for case and outbreak investigation, contact tracing, monitoring of exposed individuals, and communication with affected persons. CalConnect was developed during the COVID-19 pandemic and has now been expanded to support the mpox response. It has also been utilized for monitoring persons exposed to Avian influenza and Ebola virus disease. CDPH plans to leverage the calconnect functionality to address other priority conditions that require case investigation and contact tracing, such as tuberculosis, HIV, syphilis, perinatal hepatitis B, and measles.

CDPH received an appropriation of $39.6 million in 22-23 to provide one year of MNO funding for CalConnect. The one year funding strategy, as with Sapphire, was designed to allow CDPH to obtain updated costs through a recompetition in 2022, CDPH carried out a new procurement process, resulting in a new contract with the existing vendor.

Third, to support data system modernization efforts, CDPH requests $3.8 million for licensing, maintenance, and support of the infrastructure and security protocols needed to support public health surveillance and response systems and departmental data, including confidential protected health information. The funding requested is needed to maintain and operate CDPH technology infrastructure in its current state, support critical public health services statewide, prepare for and respond to future public health emergencies, and to leverage the technology developed for COVID-19 to address other conditions that impact the people of California. Thank you, and shall I go ahead and address the two questions that were included in the agenda?

Please do, Mr. Watt.

Thank you. So the first question was to explain the connection between this proposal and last year's BCP entitled Disease Surveillance Readiness Response, Recovery, and Maintenance of IT operations. As I indicated, for fiscal year 22-23 we requested one year of funding for the CCRs and CalConnect systems so that we could conduct recompetitions for both systems, resulting in updated costs. As I said, those recompetitions were done and now we're requesting continuation of maintenance and operation costs.

And then the second question was, what is the total cost and timeline of this project? These two systems are in maintenance and operations and are planned to be an ongoing part of the CDPH portfolio of IT systems used to monitor and control reportable diseases. The CDPH will refine future cost estimates as the IT strategic planning process in the Department proceeds in conjunction with the future of public health planning. Thank you.

Department of Finance.

Nothing further to add.

LAO, we have no concerns for this proposal.

I will bring it back up to the dais for member questions. Dr. Wood?

Yeah, thank you. My question is, does this CalConnect, is this system also used for surveillance of vector control, like mosquitoes and other vectors?

No, the calconnect system is not used for surveillance of vectors per se, and we haven't used it or we haven't projected to use it for surveillance of vector borne diseases. We've been prioritizing those conditions that are where there's a heavy component of case investigation and contact tracing as part of our usual public health response.

So I guess my question is, what system do you use for vector control? There is significant tracing involved in that, so it seems logical that might fit here. So where are you tracking and investigating vectors?

We have a couple of systems that we use for that. So we work in partnership with UC Davis to operate a comprehensive vector surveillance system that is monitoring the vectors themselves. So that is mosquitoes and other systems where we track vector borne viruses. So that system is in place for the vectors, and then we use the CalReady system to monitor cases of human disease associated with vector borne viruses.

So do you also work with the local mosquito vector control districts? Are they feeding into the same system?

Yes, they are, and we do.

This is a pretty robust system. We've got a mosquito issue that's been brewing, for lack of a better description, since, for the last 10 years that's starting to rear its ugly head and become a bigger problem. So why wouldn't those issues be here? You talk about influenza, you talk about Avian influenza, Ebola, other infectious entities. Why wouldn't you put them all in the same system? Why wouldn't you feed it in?

Great question. What the CalConnect system has is it's like a toolbox that has a set of resources that we can use for different infectious diseases. So depending on the disease and the control strategies, we can use resources that are available in different systems. As I mentioned, the system with UC Davis is really designed to specifically track vector borne diseases. So that's our primary focus there. CalConnect tools have been very useful for COVID-19 for mPOCs and the other conditions that you mentioned. If we needed them, we certainly could. But at this point, the rollout is planned for other diseases that are more aligned with the CalConnect toolbox, and we have other systems that are specifically designed for vector borne diseases.

Okay, one final question. I'm sorry, I just don't mean to beat an insect down here, but is there some threshold by which something rises to get eligible for CalConnect? I mean, I don't know that we have that many cases of Ebola in this state, but I think we have a lot of vector control or vector related illness in the state. So it's still a little appreciate that we've got a system with Davis, but I just don't understand why we wouldn't want to have everything more centralized.

Dr. Aragon.

Yeah, so maybe I can clarify. So the difference is, with COVID influenza, they're person to person transmissible. And so that's really sort of the key thing. So these are communicable diseases, person to person. And the challenges that we have is that people work in one county. Let's say they get infected in one county and work in another county and just put all that together. And you have this complex social network of transmission.

And so it's really hard for the counties to do contact tracing and case investigation of that complex transmission if they're not connected to CalConnect. So CalConnect sort of operates at this high level and allows all that contact tracing and case investigation to happen. In contrast to a mosquito borne pathogen, if you become infected, you don't transmit that to somebody else. So that's the biggest difference is really the case investigation and contact tracing for person to person communicable diseases.

Okay, thank you.

And STDs is another really good example of that, HIV, et cetera.

I will bring it back up to the chair. Mr. Watt, are these one time funds, 74.4 million for the maintenance and operations?

Yes. There for one year.

So I understood why they were one time funds last year as we were going through a procurement. But I'm questioning, since we plan on standing up these systems, why we aren't planning on ongoing funding for these systems, and I'm hoping you can comment on that.

Sure. That's related to our broader IT strategy work, and I think John Roussel is there who can respond to that question.

Sure. So the terms of both these contracts are three years MNO. With two year optional.

Can you speak into the mic a little bit?

Sorry. Both the terms of these contracts are three year MNO. With two year optional years for a total of five years. Last year's request was limited to the current year only, and CDPH was submitted another BCPA in the fall of ongoing funding of continuation. We don't want to continue to fund these without understanding the total strategy of the future of public health and have it go and build siloed systems again. We'd like to put it all together once we solidify that strategy going forward, so we can build a good foundation for surveillance itself with core capabilities going forward.

Thank you. With that, we will now move on to issue 12. Issue 12 is the proposed public health workforce investment reversion to be presented by Susan Fanelli, who is the Chief Deputy Director of health, quality and emergency response at CDPH. Ms. Fanelli yeah.

Good afternoon, chair and members. I think in terms of the questions on this proposal, first of all, I'll say we were prioritizing the ongoing 300 million for future of public health. I'll turn it over to finance in terms of why this reduction?

Nick Mills, Department of Finance due to declining state revenue, the budget proposes reducing a portion of funding included in the 22 Budget act for public health workforce investments. This reduction is consistent with the administration's overall approach to addressing the budgetary problems through delays or reductions of some spending in the near term where feasible. The Governor's Budget prioritizes ongoing commitments approved in previous budgets.

That includes public health infrastructure and staffing resources, such as 300 million ongoing for state and local health departments, a significant portion of which is for new staff, as well as ongoing workforce and upskilling programs included in the 21st century public health ITBCP approved in the 22 Budget Act.

Ms. Fanelli, can I have you go through a bit more of the BCP and understanding what effect this would have, please, on public health workforce investments?

Sure. So, this money is intended to fund a number of different programs including Pathways, which is a pipeline program, the CalEIS Fellows Program, the career ladder and upscaling program, Public Health Microbiologist Program, and our laboratory director training. And so, with these reductions, we are able to honor the commitments of this first year, and we can provide more detail in terms of the number of people we can train in each of these separate programs. However, as we look forward, most of these programs that are currently being supported by these workforce development funds, as well as some of our COVID funding and maybe small bits of funding from prevention block grant and from our public health emergency preparedness program. Most of these would go away at the end of not only this current year, but some of the programs run into the budget year. So these reductions would, in effect, end these programs.

Can you respond to the questions on page 44?

The first one is to provide an assessment of the public health workforce, and are we more or less prepared for the next pandemic? And so I would say the pandemic certainly pointed out gaps in public health infrastructure, and it's a challenging question to say, are we better prepared for the next pandemic? I think on the one hand, ee have developed a great deal of expertise and promising practices throughout the pandemic. Things like our more effective media campaigns and communication strategies.

Things like addressing miss and disinformation that's out there. Our statewide vaccination campaign with over 80 million shots administered in a very short period of time. Our predictive analytics and modeling teams, our hospital and healthcare facilities improved our surge strategies with many lessons learned and plans developed which will help us in the long run. We will leverage those lessons learned about scaling up existing facilities rather than building alternate care sites and some of the other efforts we had.

We've leveraged technology platforms so that we're more efficient and quickly can capture and analyze data. We've improved and enhanced our ability to quickly distribute medical countermeasures. Maintaining our warehouse with pharmaceutical capabilities such as temperature control and secure storage will be essential to continuing that. We've navigated and responded to many supply chain challenges. We put systems in place so that our staff are more effective and efficient, such as reporting templates and standardizing calls.

We have identified some gaps in state staff, some of which have been filled in the past year through contracts, and are working to add some of these new skills to our permanent staff, using largely our future of public health funding and some continuing federal funds for the next year. On the other hand, having enough trained staff was and continues to be challenging.

The stress of the pandemic has meant a loss of staff at the State Health Department and in our local health jurisdictions, including leadership positions which aren't easy to bring back. Our local partners, I'm sure will talk in the next session about the turnover of health officers and health directors and the impact that that has had. We'll continue to use our future of public health funding, our federal funds for the next year, and the workforce development funding that we do have to build and retain staff and build a pipeline for public health.

The third question is, are there federal funds available to backfill the reduction?

Very limited federal funds. The federal funds we have for COVID that have been supporting some of these efforts, like our microbiologist training. Those expire at the end of June of 2024, and they're limited accessibility. We're using some of those to augment the programs now. So I would say there's very limited federal funds.

So Will Owens, LAO. We would just note to the legislature that may wish to evaluate how a reduction in public health workforce may impact its broader goals as far as sharing up public health infrastructure. We noted in our recent post about healthcare workforce more broadly that the focus on budget solutions for limited term General Fund augmentations is prudent given the state's current budget situation. However, the legislature may wish to ensure that the governor's proposed solutions don't impede legislative priorities or disrupt existing programs.

And to the degree that this public health workforce reduction may do that, there's a very real chance that this budget solution may undercut those broader legislative efforts that have been passed in recent years.

Thank you. We'll bring it up to the dais for any member questions, beginning with Dr. Jackson, then Dr. Wood.

Thank you very much. I'm reminded of the reports that we continue to see. Obviously, California will be facing more frequent pandemics and public health emergencies. Well, I know for sure this is not something that I'm supportive of. I think that every time I'm going to a budget hearing now, I get flashbacks of when my paycheck came in and I wondered where the heck did my money go?

And I was short, and I had to decide whether I wanted to get rid of Showtime or whether I paid my electricity bill. I'm not saying it was an easy answer for me, but the idea is I chose the electricity bill. And unfortunately, as I see the budget, I still see a lot of HBO and Showtime in the budget.

I still see some fat in the budget that I think we can reprioritize for something as central and important as public health, especially as it relates to our workforce. And so I'm more than happy to continue to dialogue and find out where, if this is a well, where are you going to cut? Kind of question. I'm more than happy to provide a list of where we should be cutting in order to be able to do these things. But I think this is something that, I think it would be bad public policy, bad budgeting for the public to agree to such cuts. Thank you very much.

Yeah, I agree with Dr. Jackson. I have real problems with this. We fought hard a couple of years ago on workforce budgeting and infrastructure for public health, and we're told to wait a year, which we did. And now we got resources in the current budget, and now some of that is going to go away, and we're looking at potentially losing that for the future.

I can't think of any worse way to be prepared for the next pandemic than cutting our workforce training programs and our workforce investments. We were already struggling with workforce in public health before the pandemic. We've had significant burnout in a couple of my counties. We've had multiple public health directors, huge turnover in staff. And so the idea of not continuing to fund workforce is. I use this phrase all the time. It's pennywise and pound foolish. It doesn't make any sense to me.

And so we've got to find some other way to do this. It just doesn't make sense. I sat in 2017 on a workforce Commission for the California Healthcare Foundation. We identified that we needed investment over 10 years of $3 billion in healthcare workforce. $3 billion. That's $300 million a year. And that's just to kind of get us up where we need to be. Public health workforce was a part of the discussion there. So I'm sorry, we got to find another way to do this. I couldn't support this.

Thank you. I will now bring it up to the chair and we'll remind us of Dr. Aragon's words at the beginning about the waxing and waning interest within public health and the need for us to invest into preparedness and want to come back to how we helped to make this the healthy choice, the easy choice. And so would like to ask again regarding the contingency funding.

Since we didn't use any of the 250,000,000 in last year's budget for contingency funding, why was it the prudent choice for us to budget for 50 million in this year's budget for contingency funding while at the same time stripping 50 million from public health workforce? Hoping you can explain that.

I'll let finance answer that one.

Thank you, Mr. Chair. We acknowledge from the Administration that these are very hard decisions to consider. As my colleague previously mentioned, we are maintaining the 300 million ongoing, which, if folks will recall, includes 200 million for local health jurisdictions, of which 70% must be used for staffing. So we are maintaining a significant, again, public health staffing investment in the ongoing. But as we mentioned, the Administration aimed to balance addressing revenue shortfalls while also maintaining our commitment to investing in our state's public health infrastructure.

So we continue to maintain this priority and we believe we struck the best balance and compromise between making a difficult cut while also maintaining a very important investment in public health. Thank you.

I'll elevate if I can, that many of those investments were for current staff and weren't for addressing the burnout and loss of staff that we've been seeing. And so many of the pathway and pipeline programs are important, which is why the Legislature felt so inclined to invest these dollars in the last budget year, that we'd like to continue those conversations with the administrations as we finalize our budget.

But hope you hear the support we have for continued public health investments as we must be prepared with the workforce for tomorrow. With that, we will thank... Dr. Wood.

Thank you, Mr. Chair. And just one comment here, and I'm looking at the California Public Health Pathways Training Corp. and thinking about that. You have a workforce pathway for early-career public health professionals from diverse backgrounds and disproportionately affected communities. Now oftentimes these folks go back to those communities and we saw during COVID some of our most vulnerable communities were really difficult to get our arms around for workforce and how we communicate on vaccinations and testing and all of that.

And yet that's one of those things we're going to cut for the future. It doesn't make any sense from my perspective. So I just wanted to highlight that one because some of our most underserved, difficult, challenging communities.

And I'll just say, having met some of the people in our Pathways program, it's an incredible program. The people coming in have been from very diverse backgrounds and we've been able to support that with some of our COVID dollars. And it's been an incredible group of people.

And they go back to the communities, in general, that they come from often, I mean, not in general. I can't characterize that. But I do know that from experience, that people that go into that come from certain communities tend to go back to.

Well, they have ties to those communities.

Ties to the communities, home, family, that kind of thing. And so, anyway, thank you.

With that, we will thank very much this panel, and we'll now move on to issue 13. Issue 13 is an oversight issue on the state's pandemic response, emergency preparedness, and public health infrastructure. We will begin with Susan Fenelli, Chief Deputy Director for the Health Quality and Emergency Response at CDPH. Ms. Fanelli?

Sure. So I'm just going to go sort of right to the questions on the assessments of our strengths and weaknesses in public health infrastructure and emergency preparedness.

I think our strengths, one I would put up there, the development and maintenance of our public health and medical response structure with our local partners. The development of our regional team as well, regional disaster medical health specialists, along with our MOOC program, medical health operational area coordinators, has really been not only helpful for COVID, but for every medical and health response.

Although we've had categorical funding that has led to specialized staff in specific diseases, public health issues, I think we've recognized the need for more generalists who can be shifted into response roles across different kinds of events. And over the past few years, we have been able to cross-train many staff that we want to retain and are using some of the dollars that we're getting to do just that.

We've increased the number of subject matter experts who continue to work at the national levels as experts in their fields. That day-to-day work really prepares them for emergency response. Examples include things like our vaccine infrastructure, our infectious diseases, our hospital-acquired infections group, environmental health and industrial hygienists, and maternal and child health. Our weaknesses.

With declining preparedness and response funds over the past years, we're much more limited in the number of response staff that we have through these federal dollars and our ability to scale for multiple or large disasters. As we see, we're activated nearly every day for some kind of a response. And so I think that does just lend itself to making sure that we have trained staff and that we are able to use the dollars that we're getting for Future of Public Health to continue to build that.

Again, that increasing number and frequency, and severity of emergencies is challenging. Communications teams need to be expanded to address the many demands for information across a variety of platforms, and some of those are really new things. And so I think we've recognized that some of our gaps really are those kinds of things that we have not had to do in the past, that they are new skills and new complex problems that we're dealing with.

So I don't know if you want to let the others respond to that or you want me to go through on the investments, the updates on the implementation of the 300 million sort of wrapped together.

I would go through your portion.

Okay, sure. So the first year of the Future of Public Health funding has really been about filling our critical state and local health department positions with diverse representative and highly qualified staff. So for state operations, we've prioritized hiring by adding additional resources within our HR department. We have used LEAN to streamline our hiring process. We have set up a team to assist programs in preparing the need of paperwork.

In addition, we are recruiting in new ways, including additional advertising sites and grouping interviews for multiple positions within a specific classification. There's been a strong start and continued momentum for the public health workforce expansion. Both the state and local level have exceeded our hiring targets for the first two quarters, with over 700 new public health staff hired statewide throughout this investment.

We've hired about roughly 40% of our 404 positions and we're on track at the state to hire 80% of our staff in the current fiscal year. We've invested funding in a number of workforce areas, including LEAN transformation, trauma-responsive training, improving internal communications, and many efforts towards recruitment. At the local level, they've hired nearly 50% of the projected at 1,200 positions, and so very impressed by that and with all the challenges in hiring.

We're continuing an aggressive focus on recruitment, conducting campaigns to address hard-to-fill classifications, and strengthening outreach to improve workforce diversity. We've worked to reorganize several of our offices and really enabling waves of hiring. Our efforts have also required the establishment of two new offices which were approved by CalHR in December, including the Office of Policy and Planning and the Regional Public Health Office.

We've already hired the Deputy Director for the Office of Policy and Planning and are actually about to interview for the Deputy Director for the Regional Public Health Office. And several positions have been hired into these offices and recruitment continues. As part of their scope, these offices are coordinating central monitoring for performance tracking and support for implementation for this investment. As part of the LEAN transformation, we have launched new structures and system improvement efforts.

CDPH released a continuous improvement plan to boost the department's agility and responsiveness in addressing complex public health challenges. We've launched the lean improvement projects for hiring, contracting, and regulations packages at the local level. CDPH issued a guidance document to all jurisdictions, which we continue to amend as we make changes to what's allowable with these funds. 60 of the 61 jurisdictions have received their advanced payments. One has opted not to.

100% of the jurisdictions have developed detailed work plans and submitted quarterly updates on expenditures, hiring, and progress towards meeting their objectives. LHJs report expanding their workforce in multiple priority public health areas, including infectious diseases, chronic disease, community health, family health, and environmental health. LHJ's priority commitments include using funding to promote equitable outcomes and prevention and health promotion in their communities.

I would just say that as we look to the future of accountability measures for the Future of Public Health, we're looking at where we have planned investment areas both at the state and local level, and we're working with our local partners to establish statewide metrics, which will be issued prior to the start of the new fiscal year.

The focus of these metrics will be to reflect progress on addressing gaps in core public health infrastructure, improving capacity to deliver foundational public health services, contributing to long-term improvements in population health outcomes. And we've already begun that work with our local partners, and we'll continue to meet with them, so I'll stop there.

Our next speaker is Christine Siador, who's the Assistant Director of Policy, Planning, and Performance at CDPH. Please begin.

Thank you Chair and Assembly Members. So the question I will answer is, are we or will we be more prepared for the next pandemic or next public health crisis than we were before the COVID pandemic? The answer is yes, but that's dependent on our ability to retain staff to better integrate and upgrade our data systems and our ongoing Future of Public Health funding.

In building on the lessons learned from COVID response, we are trying to update and broaden our data systems to accommodate new threats, train our staff to work across multiple infectious diseases, and expand our preparedness and response infrastructure. Much of our funding for this work will be federally funded. Work was federally funded in the current year, budget year, and most of those funds we anticipate will end by June 2024. So the investments from the Future of Public Health is critical to this effort.

How will the state measure progress, and how will we know we're better prepared? We are reviewing each of the response areas to identify best practices and lessons learned and opportunities for additional preparedness work. CDPH will prioritize our work that needs to be done, tracking progress and completing the action items, developing our objectives and key results framework. We were already able to respond to Mpox much more quickly, with resources in the community to vaccinate more rapid testing capacity and updating systems like CalCONNECT to help with investigations.

We'll continue to do annual exercises and do response training, tracking the number of people able to fill various response roles, building on our gains in infectious disease surveillance resources to be broader than COVID. That is our commitment and to continue to support small segment of modeling team, the call center core that can begin response and options for scaling up in pretraining data systems, and others.

We are expanding our communications capacity and we're collaborating with multiple academic partners to incorporate information and lessons learned from this pandemic to inform algorithms, projections, and other evidence-based work to inform future infectious disease emergencies and pandemic policies and response. CDPH and local health jurisdictions are working closely to track progress and the impact of critical public health infrastructure investment. We are measuring accountability focused on efficient implementation. We're looking at rapid dissemination. We measured a rapid dissemination of local assistance funds.

We're monitoring state and local progress on expenditures. We're tracking metrics related to hiring, recruitment, outreach, and processing times. We're looking to progress in instituting systems and process improvements, and we're looking at our outcomes and impact. We're addressing gaps in core public health infrastructure and we're improving public health foundational services and population health outcomes. Thank you.

Next we have Julie Nagasako. Not sure if they have any comments.

My colleagues. Thank you.

Thank you. Our next speaker is Oussama Mokeddem, Director of State Policy at Public Health Advocates. Can you please begin?

Good afternoon, Mr. Chair Members. My name is Oussama Mokeddem, and I'm the Director of State Policy at Public Health Advocates. At Public Health Advocates, we believe that preparation for future emergencies should be a top priority. I frequently pose this question to people. If I were to transport you to 2018 and ask, in a couple of years there will be a novel virus that sweeps the world, and who would be most harmed? What would your answer be?

Everyone in this room could accurately predict that low-income people, people of color, older people, and medically vulnerable people were going to be at the highest risk for getting the disease and succumbing to it, and that the impact would likely be compounded by other factors that made them high risk in the first place. We could have predicted that all of that without even knowing what the disease was. And this brings me to key lesson number one.

The patterns of community vulnerability are well known, which means that there were opportunities for prevention that we did not take advantage of with COVID-19. COVID-19 as devastating as it was on the global scale, provided us all with a wide variety of learnings. We now have an opportunity to prepare so that we do not repeat the same mistakes in the future, because there will inevitably be future emergencies.

The answer to the question of are we or will we be more prepared for the next public health crisis is this. If we aren't already planning for the next crisis, the answer is no. If we are waiting for it to happen, to allocate resources, develop infrastructure, and hire staff. Again, the answer is no.

Luckily, as I've mentioned, the shortfalls of the COVID-19 response have been well documented by state and local health departments and community partners, so we can be more prepared if we heed the lessons from COVID-19 which brings me to key lesson number two. We must start the response now. Before the state begins the usual process of ending temporary COVID-19 staff reassignments, the staff should help develop emergency response plans that draw on the lessons they learned.

These state and local staff should be tasked with developing response plans for known emergency threats to public health, such as novel infectious diseases, wildfires, flood, extreme heat, extreme cold, tornado winds, mudslides, drought, and earthquakes. And it's worth noting that California has experienced all of these within the past 12 months which brings me to key lesson number three. Build the administrative infrastructure now. Often, the declaration of a state of emergency precipitates the availability of new resources for emergency response.

The state should establish a way to pre-identify staff roles, conduct ongoing training and planning, and prequalify community service providers to ensure that when funding is allocated, it can be distributed immediately.

We will know we are better prepared for future crises if we have a plan and funding available to ensure the following. One, messages and materials that are immediately available in the 17 threshold languages spoken in California, cultural brokers being identified and funded to provide outreach and services in culturally and linguistically appropriate ways, partners who are equipped to serve rural populations, a plan to reach people who don't have regular access to technology. And that's a very real concern, even in a state like California.

Protections for public health workers supporting basic needs such as food access, emergency housing support, and education, including schools and daycare centers, and, most importantly, that public health departments are equipped and staffed to lead the response efforts. On the topic of public health professionals, I'd like to take personal liberties on behalf of Public Health Advocates to note that my supervisor, Dr. Flojaune Griffin Cofer, is an alumni of the Cal Epidemiological Investigation Fellowship.

Prior to joining our organization, she worked at the Department of Public Health for seven years and supported the Zika response efforts. Public Health Advocates in the State of California benefit regularly from the $40,000 investment that it made in her training 17 years ago, and we can measure our progress by recognizing in the aftermath of a global pandemic that public health training programs are among the many investments that need more money and support, not less.

As we can see here, the path to prevention and investment in emergency response and our public health infrastructure isn't a speculative one. It's one that's supported by documented, tried, and evidence-based data. It's now our job to keep up the investment that we originally projected for us to achieve our goals. Thank you for allowing me to speak today and provide this perspective.

Our next speaker is Michelle Gibbons, who's the Executive Director for CHEAC.

Good afternoon, Chair and Members. Michelle Gibbons with CHEAC. First and foremost, I just want to thank this Legislature for your leadership in prioritizing public health and the public health workforce. I remember coming before this Subcommittee a couple of years ago to say, hey, we have some needs, we need to invest in the infrastructure. And you all responded and showed tremendous leadership. So thank you for that. And we are doing our part at the local level, my members, to really start to rebuild that workforce capacity.

The 200 million that local health departments received, I just want to be very clear. We didn't come and promise new, shiny things. We said this is going to allow us to hire people to do the things that we're required to do today. And as you hear, there's a myriad of public health challenges that are new and exacerbated, and growing. But these dollars were just to do the basics, the foundational things that we said we didn't have enough infrastructure to do.

I do also want to note that as Dr. Aragon stated, CDPH administers over 200 programs. Many of those programs, our local health departments are key partners with the Department of Public Health to really make sure that they're administered locally as well. So with the funds of the future public health funds, you've heard local health departments have plans to hire nearly 1,200 positions, and that is great to hear. So far, we've filled nearly 50% of those just within the first few months.

The vast majority of those positions, though there are geographical differences, is to support chronic disease prevention and communicable disease prevention and control. The funds enabled several jurisdictions, many of them actually, to hire some of the temporary workers that helped to support them during COVID-19. And I just want to make note of that because I think as we move forward, the hiring challenges are going to be exacerbated. We're not going to be able to just pool everybody that was working with us before.

Some jurisdictions need to find new people, and that is a challenge for us. While we're excited to hear about the hiring that's happened already, as mentioned before, our local health departments have been faced with harassment, burnout, and staff turnover. I'll just tell you, in the last three years, since the pandemic begun, my new count is that California has lost over 75 local health department leaders. So that includes health officers, public health directors, and agency directors as well. And that number just grew even this week.

So it is an increasing number, unfortunately. And we are sure that the staff capacity is being reflected in the same way that there are a number of departures that are happening. Last year, the Legislature prioritized these workforce and development dollars, and I'm not going to repeat much of what is said. Dr. Wood, I'm not going to repeat what you said about what Pathways is, but I do want to tell a quick note. The inaugural cohort was 45 slots roughly. They had over 900 applicants.

There is tremendous interest in this program. I actually had an opportunity to talk to the cohort and there was an older gentleman and he said, I know I'm an older face, but I am new to public health and I am loving what I'm doing. So there is an opportunity to grasp these eager individuals and bring them into the Health Department. The Cal-EIS program is the training program for epidemiologists since 1989. Just look at these numbers. Since 1989, there have been 228 graduates.

81% of those graduates work in governmental public health, and 80% of those 131 people are working in California public health departments. That's great results, small numbers, and we need to grow that. The microbiologist certification training allows individuals to gain the experience that they need to sit for the exam so that they can get certified. If we don't increase the slots to the training, we don't get certified microbiologists. These are the people that actually sit in the laboratories and they run the specimens. They're vital.

We can't replace that, but we need to continue to grow that pipeline. The Lab Aspire program is intended to grow the pool of eligible people that can serve as a lab director. I just looked at the most recent data on the Department of Public Health side. They have in 2019, the graduating cohort, excuse me, was four people. Two of those are working as public health lab directors today. Again, good outcomes, small numbers. The Public Health Workforce Career Ladder Education and Development Program.

This was the newer piece of the workforce development programs, and the Department did a great job at soliciting applications from across the state. Many local health jurisdictions responded.

I will tell you that my understanding is that the amount of funds requested in the response already exceeded the full amount of funding that was provided. And so to slash this means that we're going to have to make tough choices about what to fund and how many years it can be supported, when these are real programs or ideas to do things like help further somebody's education so that they can promote within and not leave. We've been asked, is California prepared for whatever is next?

My answer to you is this. In order for California to be prepared, we need to have the skilled and trained workforce. There is no discussion about preparedness in California without local health department staff and workforce and being trained and growing that pipeline. We know that California is navigating a tough fiscal crisis. We understand that. I would just mention that the proposal for the workforce and development cuts for public health was the only one that was a full-on cut.

It wasn't a trigger, it wasn't a delay, although we wouldn't like either of those either. But it really shows that there's not a value that's really being placed on the public health workforce. I understand what the Department of Finance is saying by sustaining the 200 million. The difference is that the 200 million builds the workforce capacity, which means adds positions at the local level. These cuts, the funds that we need for those programs, that helps to get people in those positions.

And that's a real vital necessity for California. Our public health infrastructure and workforce has been decimated over decades. It's going to take a while to rebuild it. And we knew that when we asked for these funds and these investments that it was a starting point, not the end game. And so California, really, we can't wait to continue to fund and grow our workforce, and we can't pull back on these investments at a time where we know it's needed. Thank you.

Thank you. I will bring it up to the dais for any Members' questions. Our next speaker will be Kim Saruwatari, the Riverside County Public Health Director and President of CHEAC. Thank you for traveling all this way from Riverside to speak with us today. Please begin.

Thank you. Good afternoon, Chair and Members. I'm Kim Sarawatari and I am the Public Health Director for Riverside County and also the President for the County Health Executives Association of California, or CHEAC. Thank you for having me here today to share the impacts of the Future of Public Health funding on Riverside County's public health infrastructure. And thank you also for your leadership in ensuring continued investment in public health infrastructure. So COVID clearly highlighted the impacts of decades of disinvestment in public health infrastructure.

We met a worldwide pandemic with an understaffed and undertrained workforce. We worked with antiquated data collection, reporting, and analysis systems. We faced insufficient laboratory capabilities and capacity, and we struggled with inadequate strategies for reaching our most vulnerable communities. As an example of our understaffing in Riverside County, we had to expand our workforce from 700 FTEs to 1,500 FTEs in a matter of weeks to be able to respond to the pandemic.

Today, I'm happy to report we are making great strides in improving our public health infrastructure and our ability to respond to emergencies while caring for our most vulnerable populations. We're not where we need to be, of course, but we're headed in the right direction, and much of that is due to the $200 million Future of Public Health investment provided to local health departments in Riverside County.

We received about $11.8 million of this funding, which allowed us to both hire new positions as well as transition temporary, COVID-funded positions to permanent. In total, we're funding 131 positions, or 96.7 FTEs, with Future of Public Health funding to improve our capacity in communicable disease response, chronic disease, and community health, including climate change, data modernization, reporting and analysis, emergency response, laboratory capacity, and outreach and education, particularly to our most underresourced communities.

We've hired or in the process of hiring nurses, microbiologists, epidemiologists, communicable disease specialists, community health workers, health educators, accountants, couriers, and others, all with the goal of serving our community, improving the overall health of our residents, and enhancing our response capabilities. As of today, we've filled 68% of those 131 positions that are supported by the Future of Public Health funding, and the rest are in active recruitment. And while we're proud of the progress we've made filling positions, we are struggling to find qualified candidates.

And that struggle is only increasing because every health department across the state is struggling to find the same candidates that we are right now. In Riverside County, our current vacancy rate is 22%, and the average length of time it takes to fill positions is approximately six months. To give you an idea of how long it takes to recruit qualified individuals in key positions, our public health laboratory director position has been open for three years.

It's taken 12 months to fill physician positions, licensed vocational nurses, eight months, registered nurses, seven months, epidemiologists, six months. If we truly want to build our public health infrastructure and be able to recruit the talent that the public deserves, we need to build our pipeline of qualified, skilled, and passionate individuals. And that's why, of course, we're very concerned about the $49.8 million cut in workforce development funding for public health.

Without these funds to develop a pipeline of qualified individuals, health departments will continue to struggle to fill positions. My health department has experienced the value of these workforce development and training programs. We've had the opportunity to host one pathway fellow and requested another. We currently have three microbiologist certification trainees, and we have had two Cal-EIS fellows. One that we hired permanently, and we've also requested another. Again, small numbers, huge impact for us.

As part of rebuilding public health infrastructure, we must invest in our most valuable resource, the people. These people work tirelessly, day in and day out to protect the communities we serve. The investment we make now to develop a pipeline of qualified, trained people will come back many times over because we'll be able to respond quicker, more efficiently, and at less costs.

If we invest in our people, we're investing in our future, and we will be in a better position to respond to the next public health crisis. Thank you so much for your time today.

Our next speaker is Beth Malinowski, who's a government affairs advocate for SEIU California State Council.

Chair and Members. I'm happy to be here today on behalf of SEIU California, our 700,000 members, including state and local public health workers throughout California. SEIU members know well that we cannot make the promise of health equity and justice a reality without critical public health investments. We're grateful for the foresight of this Committee to be hosting this panel today.

The past few years have served as a brutal reminder to all of us that how we fund public health can fuel or dismantle public health progress. On that note, I'd like to briefly share with you SEIU's perspective on recent public health investments, the avoidable funding cliff that we're now presented with, and our vision forward, which parallels nicely those comments made by my peers.

Throughout this pandemic, SEIU is proud to have partnered with stakeholders and this Legislature to guarantee that California State and local public health departments could pivot to a pandemic response and successfully maneuver our state through the pandemic. Our public health workforce jumped into new roles, took on new training, new duties, new risks, all the service of making sure California can not just survive, but thrive, and our public health workforce in our communities, our staff at CDPH, the Legislature stakeholders should be proud of this.

The pandemic forced us all to revisit a big question, a question that doesn't often get the attention it needs. Are we sufficiently funding public health? As we grappled with this, especially in recent budgets, we set some really important intentions. We put an additional 300 million annually towards public health, making a long-term commitment to state and local infrastructure. Last year, the California Can't Wair Coalition also put forward an additional request of 180,000,000 in new workforce investments needed to retain and expand public health workforce. Why?

Why did we do this last year? Because the infrastructure investments alone are only as strong as a workforce that stands behind it. So, as this body knows, the final FY 22-23 budget included some, but not all of those workforce investments. That brings us to today. Confidence in our public health infrastructure can be seen in the Governor's recent action to end California's public health emergency. The public health environment, though as a whole, hasn't changed. We're still living with COVID-19.

Infectious diseases can become a new pandemic, our reality, and climate change poses new public health risks. We should not and cannot mistake the removal of that declaration as a certificate that the work is over, because it is not. While I'd like to be sitting here talking about how we are poised to build on our public health investments, instead we are faced with a proposed FY 23-24 budget that does the opposite, eliminating roughly 15 million in public health workforce investments.

As others have spoken to, now is not the time to backtrack on our commitments even before they've begun. State and county public health cannot be successful when we play a game of cat and mouse with workforce funding to use the Incumbent Worker Upskill Training program as an example. Soon after the FY 22-23 budget wrapped up, stakeholders began meeting with CDPH staff. We got applications out to counties and we received great proposals back.

Some of these proposals include a multi-year commitment to their staff, commitments around education that cannot be accomplished in one or two years. But now we're faced with a difficult position. How do we make decisions in this uncertain environment? How do we allow our counties to make a commitment of multi-years to their workforce when we don't know the state dollars will be there for them?

These public health workforce challenges are a reflection of broader public sector challenges, understaffing, failure to hire, fill vacancies, and over-reliance on registries for staffing needs. These challenges, they're fed when we pull back on these workforce investments. We are harming ourselves, our ability to do the daily work of public health, and be prepared for the unknown of the future. In closing, the Governor's Proposal this January highlights the ongoing challenge public health has in California, a willingness for public health to be the first to be cut.

As I sit here today, I'm not confident if we will be more prepared for the next public health crisis. My hope is that we will be, but that will require commitment to ongoing state funding, a commitment to public health workforce that can weather a bad budget year because pandemics, they don't know a bad budget year from a good budget year. They'll be here regardless. This Legislature, their actions through this Subcommittee, and throughout the session can really set us back on track.

We thank you for today's panel and welcome ongoing dialogue on this matter. Thank you.

Department of Finance? LAO? Bring it up to the dais for any Members' questions. Dr. Wood?

Thank you. And thank you to the panel for your comments. I look at investments like this as investments again in prevention. And it's not my number, but it's a number I hear all the time, that for every dollar you invest in prevention, you save $6 on the other end. And this is consistent throughout, it feels like throughout state government, we don't invest in prevention on a myriad of things. It was an issue we talked about last week as well.

I look at drought prevention, okay, it's raining out now, but we know that we're going to have another drought. But we don't invest in the processes that would help us be better prepared for the next drought. We consistently do this over and over and over again. This is a big one. This is a really important one. And so I hope that we're going to do everything we can as far as this Committee, I think to try to retain as much of the resources as possible.

But it just is mind-boggling that we could potentially set ourselves up to do what we always do and not prevent things that are preventable. And it is pretty mind-boggling. Thank you, Mr. Chair.

I'll bring Ms. Siador up, if I may. You know, I was struck during your comments. You said about the importance of retaining staff, and yet you didn't comment on recruiting staff. And so I'll highlight the Riverside director's comments about having 22% vacancies and struggling to find quality candidates. Isn't it important for us to similarly be recruiting staff and having these pathway pipeline programs, which is why we made the investment in last year's budget?

Yes. Let me address that. Yes. Our effort is to recruit and retain our staff. Recruitment is critical, right? We are trying to fill vacant positions that we've had for years, and with the departure of public health workforce, we're trying to fill those positions as well. And to be honest, we're competing for the same individuals across the state.

That is a challenge, and that's why it is important that we have our recruitment efforts and upskilling and to retain our staff, but also to have staff to recruit from as well.

I'll bring in Ms. Gibbons, but it would seem if we have 900 applicants for 45 slots in a cohort that there's much more we could be doing in terms of recruiting future public health workforce. And so again, we'll emphasize the importance of us making that investment. Ms. Gibbons?

Yeah, I just wanted to emphasize as well that a number of those public health workforce development training programs, those aren't just for locals, right? And it wasn't even just money that we said, give it to us and we'll figure it out. The reason why we asked for these programs is that there is already a statewide system in place for most of these, all but one. And even the Incumbent Worker Upskill Training, it was to support both state and local health department workforce.

So we recognize that there is a need both at the state level and at the local level. I won't speak for the state, but I will tell you, I used to work for the state, and recruitment and retention is hard. And so we wanted to be deliberate about making sure that these programs could yield success both at the state and local level, because we are all competing for the same pot.

With that, I do want to thank very much this entire panel. We will now move on to issue 14.

Thank you.

Afternoon, can you all hear me okay?

We can please begin.

So good afternoon chair and Assembly Members. I'm happy to be before you to provide an overview of the AIDS Drug Assistance Program November estimate package. I will provide a brief overview of the estimate package and then provide responses to the submitted questions. For current year the Budget act of 2022 included adapt local assistance funding of $445.1 million. The revised current year budget is $440.5 million, which is a decrease of $14.5 million when compared to the Budget Act.

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

The decrease is primarily driven by medical expansions and lower medication expenditures and premiums for the insured client groups than previously estimated. Changes to ADAP budget authority for budget year to the Budget act include an increase of $2.6 million in federal funds and a decrease in $17.5 million in ADAP rebate funds. Next, I will move on to the questions. As I know, some of the questions actually include references to our assumptions.

So for question one, in regards to the primary changes and dynamics in funding reflected in the estimate, the 3.2% decrease in current year is driven primarily by lower medication expenditures, premiums, and caseload for the insured client groups than previously estimated. While the insured medication only caseload is projected to increase, the insured client group caseload decrease more than offsets this impact. The 3.3% decrease in budget year is driven primarily by medical expansions and lower medication expenditures and premiums for the insured client groups than previously estimated.

Moving on to question two in regards to an explanation around the increase in federal funds. On June 22022 the ADAP Emergency Relief Funds grant notice of award was received by ADAP and that was in the amount of $3.8 million for the '22 grant budget period containing an unanticipated amount of $2.7 million from the 2020 grant budget period on October 25th 2022.

The 21 Ryan White Part B grant carryover notice of award was received in the amount of $5.6 million which will be spent in '22-'23. For question three, there was an ask to explain the ongoing overestimates of drug costs. OA uses methodologies in line with industry standards. For current year, CDPH is estimating approximately zero point 11% change in medication costs for the ADAP and PrEP-AP programs from the 2022 Budget Act, which is a very small decrease or very small difference.

Monthly caseloads and costs per client per month may vary per client group as more updated data is loaded into the budget projection model. In addition, due to COVID-19 and the uncertainty of when the public health emergency would end, overestimations occur to account for the potential increase in client count and medication expenditures which were due to individuals potentially being disenrolled from Medi-Cal. Question four ask for an explanation of the assumptions and conditions that are affecting the caseload projections.

And so for our new assumptions in regards to the expansion of Medi-Cal to all income eligible Californians, which will begin no sooner than January 12024 where medical will be available to all income eligible Californians. This will reduce monthly caseloads in budget year as more ADAP clients will become eligible for medical very similarly for the medical expansion with the asset limit changes.

So, due to the passage of AB 133, the medical asset test will be eliminated for non modified adjusted gross income medical programs in a two phased approach.

This change will reduce ADAP monthly caseload in current year and budget year as more ADAP clients will become eligible for medical our existing assumptions in regards to the medical expansion for individuals aged 50 and older, regardless of immigration status, this is where the Governor's Budget expanded eligibility for full scope medical benefits to this population, which will also reduce monthly caseloads in current year and budget year for ADAP.

We expect that at least half of the 2,076 currently enrolled uninsured clients between the ages of 50 and 64 years old will begin to transition to medical and next in regards to the ADAP pilot jail program, the 2223 may revision estimate approved seven counties. OA has a contract in place with one of those counties and continues to conduct outreach to the remaining six counties.

For '23-'24, OA requests approval for three additional interested counties and this gel pilot program will increase our caseload in current year and budget year. And then lastly the PrEP and PEP initiation and retention initiative. This is where AB 133 allowed for ADAP to fund local health departments and community based organizations to the extent that funds were available for PrEP and PEP navigation and retention coordination and related services, and this will also increase our monthly caseload in current year and budget year. And that is the last question.

Thank you. Department of Finance?

Shelina Noorali, Department of Finance nothing further to add.

Will Owens, LAO, nothing to add.

We'll bring it up to the dais for any Members questions. Seeing none, I will thank very much this panel. We will now move on to issue 15.

Thank you.

Issue 15 covers the baby big infant botulism treatment and prevention program, BCP, which will be presented by Katya Ledin, Infectious Disease Laboratories Division Chief at CDPH. Please begin when you're ready.

Thank you. Good afternoon, Mr. Chair and honorable Committee Members. Although rare, infant botulism is the most common form of human botulism in the United States and a potentially life threatening disease. Since infant botulism was first recognized as a novel form of human botulism in California in 1976, CDPH has led efforts to investigate and address this disease. Historically, approximately 40% of all infant botulism cases in the United States have occurred in California.

The Infant botulism program and its special fund constitute a self contained program statutorily implemented in 1996 by the California Health and Safety Code, sections 123700 to 709. After many years of work in October 2003, almost exactly 20 years ago, the Infant Botulism Treatment and Prevention program received US Food and Drug Administration licensure to produce and distribute the public service orphan drug human botulism immune globulin, also known as baby Big for the treatment of infant botulism.

CDPH is the only source of Baby Big in the world as a recognition of infant botulism, disease has increased. Utilization of baby big has increased. Calendar year 2022 utilization reached an all time high of 218 treatments, surpassing the previous year's record of 206. This proposal requests authority to encumber a total of $67.8 million of the Infant Botulism Treatment and Prevention program's Special Fund over the next five years from 2023 to 2028 for the manufacture and distribution of Baby Big.

This proposal is specific to the Infant Botulism Treatment Prevention program Special Fund, which has a healthy balance and ongoing revenue and does not affect the General Fund. The additional encumbrances requested are needed for the upcoming five year manufacturing cycle baby big to offset inflation related increases in personnel, operating, and regulatory costs.

The requested encumbrance does include some overestimates due to the ongoing issue of misalignment of manufacturing vendor calendar years with agency fiscal years to provide sufficient authority for expenses that need to be shifted from June to July, August time frame. The costs of baby big manufacturer are fully recouped through fees charged per treatment, which are paid by hospitals and insurers. Distributions of baby big have continuously increased as more cases of infant boxes are being recognized, so no fee increases needed at this time.

However, program is closely monitoring the cost of manufacturing distribution and is prepared to increase fees in future years as needed to offset any increases in cost due to inflation. Shall I answer the question as well?

Please do, yes.

So, in answer to the question about research for alternatives to baby big that does not rely on human subjects or plasma. Research into botulism, yes, research into botulism, one of the most toxic substances known to humans, is very highly regulated by the US government and the military. The US government has been funding programs to develop monoclonal antibodies against botulinum neurotoxins as military and medical countermeasures for adults. So combinations of investigational monoclonal antibodies have undergone animal studies and very early phase studies in adults.

Additional clinical data would be needed and multiple regulatory steps in order to determine the safety and effectiveness of antibodulum monoclonal antibodies to treat infants. That means that the development of a safe tested and FDA approved alternative to baby big for the treatment of infants is potential, but is still many years away, potentially a decade or more, as we know that infants are the very last group that has safety trials done after something after a substance is proven safe in adults and other age groups.

That concludes my information. Please let me know if there's any questions.

Department of Finance, Shelina Noorali nothing further to add.

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

I will bring it up to the dais for any members' questions. I'll keep it here at the chair. I'll first if I can. Ms. Ledin, I think we answered the wrong question. The question we were trying to ask was who pays the fees that support this program? And is there any reason to believe that the fee increase could be a hardship for anyone?

So the fees are paid by hospitals and insurers and as far as we know, we haven't had situation where the fee was not able to be paid, so we don't believe it's a hardship. And of note, the fee is for the complete treatment regardless of how many doses are needed per patient.

I will say I took interest in this as we are the only one in the world who are currently making this treatment. And yet, what stuck out to me is that based on a five year average, approximately 30% of the treatments are distributed here in California. We don't have 30% of the children in our nation yet, let alone the world. And I'm wondering how we can make sure that this medication is available for all who may need this treatment.

The program makes every effort to make the medication available, and it's incredibly responsive. They have a 24 hours, seven day a week contact number and they ship overnight. The main obstacle for us is recognition of this rare disease, and we find that as the program is able to make its findings known to the international medical community, there's more and more recognition of cases.

So California leads the case recognition, but we are sure that the use of this treatment has not been saturated anywhere in the world because every year more and more cases are recognized.

Having seen this firsthand and seen the treatment, I know how impressive it is for us as a state to be producing this, and again, just want to elevate and thank the Department of Public Health for creating this. With that, we will thank very much this panel, and we will now move on to issue 17, as we will be skipping issue 16 since it has been moved to nondiscusion.

For issue 17, this covers the restroom access medical conditions AB 1632 BCP. This proposal will be presented by Maria Ochoa, assistant Deputy Director at the Center for Healthy Communities at CDPH.

Ms. Ochoa good afternoon, chair Members. Can you hear me? My name is Maria Ochoa, assistant Deputy Director within the Center for Healthy Communities of the California Department of Public Health, and today I will provide a brief overview of several of the budget adjustments for our center. So the first adjustment is for AB 1632.

The Governor's Budget reflects an increase of nine positions and $1.4 million in General Fund state operations and ongoing to implement and provide oversight for the Restroom Access Act as mandated by Assembly Bill 1632. This funding will create a new program to implement and provide oversight for the Restroom Access Act, including investigations and issuing fines as mandated by AB 1632.

The funding provides resources required to hire staff and establish a new program promulgate regulations with scope that will include building sanctions for violations, establishing the complaint review process, and establishing the due process for compliance. Upon implementation of the program, CDPH will provide statewide review of violations, complaints, conduct investigations, perform oversight and monitoring of investigations, collect fines, and conduct due process compliance. CDPH will issue fines that are the result from the investigations for complaints received. CDPH will monitor complaints by geographical area and the business type.

To identify trends and complaints. CDPH will develop a standard electronic form and post the required form on the CDPH website for those with eligible medical conditions to have signed as a reasonable evidence by a healthcare provider. CDPH will establish and maintain a database that collects violation data to track frequent violators CDPH will educate the business community about their new legal obligations through guidance bulletins and or fact sheets posted on the CDPH website.

CDPH will partner with other state departments and business associations to post an informational bulletin on their websites as well. CDPH will be responsible for monitoring and enforcement. Local health departments will not monitor or enforce this proposal because the language of AB 1632 did not give cdph the authority to require local health departments to enforce the law. CDPH will work with CHIAC and CCHLO to communicate the new regulations and corresponding fact sheets to local health departments for informational purposes.

CDPH does not anticipate that the fees collected from the fine revenue will ultimately pay the cost of the program because the cost of the fee is $100 per fine. However, any fees collected may offset a portion of the cost of the program once it is fully implemented.

Department of Finance?

Good afternoon. Nick Mills, Department of Finance nothing further to add.

LAO we have no concerns for this proposal.

Bring it up to the dais for any Members. Questions? I was hoping, Ms. Ochoa, if you can, the fifth question we had within the agenda on page 60 regarding how the costs of this program have exceeded the estimate which was shared with the Assembly Appropriations Committee, which analyzed this bill. Can you speak to that, please?

Yes.

So originally, when CDPH reviewed AB 1632, we did believe that the cost would be minor and absorbable because our original interpretation was that we are just going to have to develop a form and post it to our website.

But after further review and interpretation of the bill, we've determined that the Restroom Access act enforcement falls under CDPH and because the new law amended the health and Safety Code, not the Civil Code, specifically adding a new section, it states that the State Department of Public Health shall implement this article. So therefore, after further interpretation, we are responsible for the enforcement, monitoring, collecting fees, and the whole implementation of the program.

With that, I will thank very much this panel, and we will now move on to issue 20, skipping issues 18 and 19 again, which are nondiscusion issues. Issue 20 is an update on the Proposition 99 adjustments within CDPH, which will be presented by Maria Ochoa, Ms. Ochoa, please begin.

Yes, we have quite a few adjustments to go over. So the first adjustment is our Proposition 99 Health Education Account Fund 0231 and the Governor's Budget reflects an increase of $505,000 in Proposition 99 Health Education Fund, including a decrease of $870,000 in state operations and an increase of $1.375 million in local assistance.

Because of the updated Proposition 99 revenue projections, the California Tobacco Control program is planning the following adjustments, so increasing $141,000 in the state Administration appropriation funds available for program training, travel and conferences increasing $1.375 million for the competitive grants appropriation that will make additional funding available for future competitive grant programs increasing $826,000 for the evaluation appropriation, which will result in additional funds available for surveillance and communicating data findings to the public and decreasing $1.493 million from the media campaign appropriation that may result in reduced specialized media efforts and decreasing $344,000 in the competitive grants appropriation, which may affect funds available for statewide technical assistance and training providers that support local programs. Next is the Proposition 99 Research Account Fund.

0234 and the Governor's Budget reflects an increase of $1.491 in the Proposition 99 research account as a result of updated Prop 99 revenue projections. The revenues are used for tobacco related disease research.

This includes funding to our environmental health branch and to our chronic disease surveillance research branch, and the Environmental Health Investigations Branch uses these funds to fund projects such as toxicological outbreak program, conducting environmental exposure investigations, asthma surveillance, and the Asthma Management Program and the Chronic Disease Surveillance Research Branch utilizes the Prop 99 account funds to conduct central operations of the California Cancer Registry, which processes approximately 5 million pieces of information annually to track cancer incidents and surveillance statewide to create high quality data for cancer research and informational program policy development and next is the Prop 99 unallocated account and the Governor's Budget reflects a decrease of $60,000 in the Proposition 99 unallocated account and the revenues are used to support tobacco education, tobacco prevention efforts, tobacco related programs, tobacco related healthcare services, and environmental protection and recreational resources, and open it up to any questions on the Prop 99 accounts.

Department of Finance?

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

We have nothing to add at this time.

LAO?

Bring it up to the dais for any Members questions. Seeing none, we will thank this panel. We will now move on to issue 21, which is an update on the Proposition 56 adjustments within CDPH. We will begin with Maria Ochoa, followed by Miren Klein, Deputy Director for the Center for Environmental Health at CDPH. Ms. Ochoa?

Yes, and I believe Miren is not available, so I will go ahead and provide her update today. So the first adjustment is the Proposition 56 state dental program account, and the Governor's Budget reflects an increase of $4.842 million in state dental program account Fund 337 including a decrease of $1.57 million in state operations and an increase of $6.389 million in local assistance. As a result of updated Proposition 56 revenue projections. The state OPs decrease of $1.57 million will be offset using Prop. 56 backfill funds.

These funds will be needed to support staffing and contracts such as an IAA with CSUs to facilitate the smile survey of third graders throughout California. The local assistance increase of $6.389 million will be used to support local oral health programs, efforts to improve oral health of pregnant women and children and will go to local oral health programs to support the smile survey of third graders. Next is the Proposition 56 prevention and control program accounts.

The Governor's Budget reflects a decrease of $2.20 million in tobacco prevention and control programs Fund 3322 including an increase of $5.756 million in state operations and a decrease of $8,000,006 in local assistance. As a result of updated Prop. 56 revenue projections.

The California Tobacco Control program is planning the following adjustments decreasing $406,000 in media campaign appropriation for reduced specialized media efforts a decrease of $4.744 million in competitive grants appropriation, which may affect funding for future community based competitive grant programs, decreasing $3.261 million to our local led agencies and increasing $2.644 million in state administration appropriation, which will allow funding for program purchases, travel, trainings, conferences and support for administrative oversight and an increase of $1.174 million in evaluation appropriation, which will result in additional funds available for surveillance and communicating data findings to the public and lastly, an increase of $2.344 million in the competitive grants appropriation, which may allow for additional funds for cessation related technical assistance.

And the last one is the Prop. 56, the Tobacco Law Enforcement Account Fund 3318. This reflects a decrease of $797,000, which may result in fewer compliance checks of retailers.

Good afternoon. Nick Mills, Department of Finance I just wanted to answer the first question here. The increase in the Prop. 56 state dental program account reflects repurposed savings from the 2021-'22 fiscal year.

Will Owens, LAO we have nothing to comment at this time.

We'll bring it up to the Dias for any Members. Questions?

Dr. Wood, I guess I'd just say I'm disappointed to see a reduction in the tobacco law enforcement account. We just had a referendum on the ballot that protected a bill passed by this legislature, signed by the Governor, and we know it's going to be challenging to enforce that law. So it's disappointing to see that we would then decrease our tobacco enforcement account. It seems counterintuitive.

We will thank very much this panel and now move on to issue 22. Issue 22 is an oversight issue on the California Cancer Registry budget. We will begin with Dr. Allison Kurian from Stanford University School of Medicine who's testifying remotely. Dr. Kurian will be followed by Maria Ochoa. Dr. Kurian, thank you.

Can you hear me?

We can. Please proceed.

Well, good. Thank you so much. Chair Members of the Committee, my name is Allison Kurian. I'm a Professor of medicine and epidemiology at Stanford University, and I'm also a practicing oncologist specializing in breast cancer treatment. I am a cancer scientist studying the causes and outcomes of cancer in the real world, not just for patients treated at a University like Stanford, but for every patient diagnosed with cancer.

I am pleased to have an opportunity today to discuss the importance of the California Cancer Registry, which I will refer to as the CCR, and to urge that the legislature take action to protect this program, which is threatened by funding restrictions. In the interest of time, my spoken remarks today will be abbreviated, but I have submitted a full written statement for the record. First, I want to share some background that shows the importance of California's Cancer Registry to my work as a cancer scientist.

For more than 20 years, I have centered my research on a partnership with CCR, which is mandated by law to track every new cancer that occurs in California. The CCR is exceptional in that it leaves no one out, whatever their age, race, ethnicity, gender, income, education, or other characteristics. Every patient's cancer journey is recorded. CCR is called a population based cancer registry, and with the national SEER program to which it contributes, they have been described as the eyes with which we see the cancer problem.

Without it, we would be blind to how a major cause of illness and death has affected the people of California and the nation across the past 50 years. The CCR thus serves as a vital backbone that anchors other data sources for cancer research.

I lead a project based on extracting data from electronic medical records using advanced technologies, including artificial intelligence, and we found that the extracted results were not intelligible or useful until we linked them to the CCR, which then enabled us to lead high impact research, such as our recent finding that LGBTQ patients have higher mortality after a breast cancer diagnosis and helped us pinpoint disparities in access to care.

This showed that the CCR cannot be replaced by an AI generated data set, which does not completely include meticulous data collection and quality controlled by trained cancer registrars. The CCR is essential to understand whether the nation's investment in new treatments, vaccines, and genetic technologies, often called precision oncology, is working for everyone. We cannot answer that question using clinical trials, which enroll only a small fraction of cancer patients.

We can answer it only with the real world view of every cancer patient's diagnosis, treatment, and survival which the CCR provides. My work with CCR has revealed racial and ethnic disparities in which patients benefit from advances such as genetic testing, and has helped us to target these disparities for improvement. The CCR is also crucial to help us understand how to find cancer early.

I have used CCR data to identify which women benefit from novel breast cancer screening approaches such as magnetic resonance imaging, and this research led to a change in the national screening guidelines and has saved women's lives. These are just some examples of the ways that the CCR has contributed toward victories in our fight against cancer, but today, this vital resource is under threat.

The CCR is funded through a blend of resources from the state and Federal Government, with most funding provided through the NCI's SEER program to California's three designated sear regional registries. These federal funds require a 20% cost share. State funding for the CCR has been on a decline due to the declining revenues from Proposition 99, California's tobacco tax, and a lack of state investment.

Based on estimates provided by the Department of Public Health in the upcoming fiscal year, the allocation of the tobacco tax revenue that funds the CCR is forecasted to have a shortfall of just under $1 million. There are currently no confirmed plans to offset this funding reduction from other sources. This cut comes on top of prior reductions, resulting in flat funding for the registries for a decade and increased funding pressures from the implementation of electronic pathology reporting based on current projections.

Because of these budget threats, California will be unable to maintain its 20% institutional cost share for the federal SEER program, and if this happens, California's cancer registry in its current form would come to an end. The negative impact on my work and that of cancer scientists like me would be incalculable. The CCR is truly the envy of cancer scientists around the country and the world. It is also critically important to eliminating gaps in health equity.

Truly, the CCR delivers vastly more than it costs for the people of California, and thus it is critical that we fund it fully and effectively. With the appropriate ongoing funding, we can sustain and strengthen our cancer registry, implementing changes that would provide real time data for researchers and clinical trials. And thus, I urge the Assembly Budget Committee to take action to protect California's vital tool in our fight against cancer in this year's budget and to protect funding for the CCR.

I thank you for this opportunity to testify today.

Thank you, Doctor. Ms. Ochoa?

Thank you for the overview. Dr. Curry and CDPH fully agrees with the importance of the CCR. So we have been working closely with our regional partners to address these issues, and I will provide a brief overview of the California Cancer Registry and how it operates and just address some of the issues that were raised. So the California Cancer Registry is projected to receive $10.6 million in fiscal year 2023-'24. This includes funding from state and federal resources.

In fiscal year '23-'24 we are projecting a shortfall of approximately $750,000 to maintain the current level of federal funding. Again, CDPH is continuing to work on solutions to address the shortfall, and it may be helpful to explain a little bit of how the regions are direct their direct funding methodology. So currently, federal funds are provided directly to their regions in the amount of $13 million of SEER funding.

To maintain the region's current level of direct federal funding, the regional registries are required to identify a funding cost share in the amount of 20% of the total federal allocation. This equals approximately $3.3 million of nonfederal funds. The regions use state General Fund allocations to meet this cost share requirement. So again, for fiscal year '23-'24 we are projecting a $750,000 shortfall which would lead to the regions not meeting the 20% level of cost share.

The regions currently have a cost share shortfall of $807,000 for fiscal year '22-'23. Although the SEER has continued to fund the regions at the full amount of federal funding, even though they are not meeting their required cost share, that could change at any time. So, in addition to this, CDPH directly receives $2.5 million from the Center for Disease Control and Prevention, CDC.

CDPH is required to put in $5 million to the cancer registry for a maintenance of effort and is required to provide 25% in matching funds to maintain the current level of federal funding from the CDC. To meet this requirement, CDPH uses General Fund and Prop 99 for the maintenance of effort and the breast cancer research account to meet the matching requirement. In fiscal year '23-'24 the breast cancer research allocation is projected to decrease by $98,000, requiring additional General Fund to meet this requirement.

Prop 99 cannot be used to meet the region's 20% SEER cost share requirement in the amount of $3.3 million. Additionally, it cannot be used to meet the state's CDC 25% matching funds requirement in the amount of $625,000. When Prop 99 allocations decrease, General Fund is used to cover the decreases, which in turn impacts the amount of General Fund available to allocate to the regions.

And I just want to note that in 1988, the cancer registry was 100% funded by the General Fund and with the implementation of Prop 99 in 1989, the CCR received Prop 99 funding in addition to its General Fund allocations. In 1991, General Fund allocations were cut altogether for the cancer registry. So continuing decreases in Prop 99 and the breast cancer research account will impact the registry as the cost share and maintenance of operations requirement to continue.

The current level of federal funding are increasingly difficult to meet. However, CDPH is committed to working on alternative solutions.

Department of Finance?

Good afternoon. Nick Mills Department of Finance. The Administration continues to evaluate ongoing costs associated with the cancer registry and how to best address projected reduced revenue that supports this program, and any requests for additional resources will be considered through the May revision budget process.

Will Owens, LAO, we have nothing to add at this time.

We'll bring it up to the dais for any members'questions. I'll keep it here at the chair if I can. My mother is a breast cancer survivor and for many of us we look towards these registries to make sure that we are providing precision oncology. She had a herd two positive receptor which allowed us to have herceptin be the treatment.

And yet it will be things like the registry that allow us to decide if there are patterns, if there's a genetic component, if this is passed on to my daughters.

And so for many of us, we look towards this registry as both the envy of the nation, but a program that we've uplifted and are quite proud of here in California as well, that I'd like to really dig in a little bit to talk about the shortfall, because it seems to be a persistent problem that has gone on since we've moved to Proposition 99. And as this was stated so eloquently, this helps to eliminate many of the gaps in health equity.

Can you explain through a lens of equity what it means when we're not fully funding this cancer registry and what impact that would have on our communities who are vulnerable?

Yes, I can speak on that. So we do agree, and part of us trying to assist in funding this fully is we really want to receive timely and complete information on statewide cancer cases and make sure that there is available research for available. I'm sorry, we don't want to miss any opportunities to promote equity in cancer prevention, treatment and survival.

So part of us making sure we're funding the registry fully is making sure that the accuracy and validity of the data that we're collecting is valid and is usable by the public and private researchers. We want to make sure that the data is good data.

Can I dig in a little bit, it seemed that there was a shortfall. Are we requesting these centers to be collecting a funding cost share? And if so, is that the most effective way for us to ensure that we are continuing to fund this, as they have not shown that ability to collect that cost share?

Are we speaking for the state reimbursement of the cost share? Yes. So in order for us to meet our CDC requirement, the state is required to put in a 25% maintenance of effort and a 25% in matching funds to maintain our CDC level of funding.

If the shortfall is not addressed successfully during the May revision, what would occur to the CCR?

If it is not addressed? There could be decreases in the accuracy of the validity of the data. The California regional registries could lose up to $6.2 million in NCI funding if they cannot provide the 20% cost share. Timely and complete information on statewide cancer cases will not be available for research purposes and may result in a loss of up to an additional $9.5 million in federal funding to the CCR.

And again, it could affect CDPH's ability to integrate the CCR into California and federal data modernization, and this could be significantly diminished.

Dr. Jackson?

As soon as you started saying, affecting the validity of the data, my ears started ringing, because obviously, if data is not valid, we shouldn't have this at all. Right? If people start wondering whether a lot of good, big decisions are being as though in the nation's great largest registry, that we should do everything we can to make sure that the integrity of the data is going to be maintained. And so obviously we need to fix this because the current proposal is simply not acceptable.

When you start Talking A. Well, I am a researcher, but if I was a researcher in another country, and I'm looking for the biggest set of data in the nation, in the United States, I would turn to this one. Right. And so we have to be careful about how we treat our data, obviously, and making sure that potentially global decisions can be made when it comes to cancer.

And so I hope we can work with you all to be able to fix this, because the unintended consequences can really be. I'm trying not to be dramatic, but big bad things can happen if we don't maintain the integrity of this data. So let's find a fix here. Clearly, this should be a priority for the State of California. Thank you.

And I will end, if I can, that I thought Dr. Kurian said it well, about the racial, ethnic, and SOGI disparities which are present within our cancer registry and allow us to design precision treatments for communities who are suffering disparate impacts to cancer and thus believe it's imperative for us to get this right and look forward to those alternative solutions.

From the Administration come May revision. With that, I will thank very much this panel and we will move on to our final issue for1 the day on issue 23. This is an overview of the WIC program estimate, which will be presented by Christine Sullivan, the WIC Division Chief at CDPH. Ms. Sullivan, can you begin?

Thank you and good afternoon. I'll provide a high-level overview of the WIC estimate and address the two questions from the agenda. WIC estimates an increase in expenditures of more than $200 million in the current and budget year, with about half of the increase due to the fruits and vegetables increase and half due to increases in inflation and participation. This increase brings total expenditures for food to $921,000,000 in the current year and $944,000,000 in the budget year.

Food expenditures are covered by federal revenue and rebate revenue. The November estimate includes projections of more than 940,000 WIC participants served each month, which is a small increase over the previous estimate. In January of this year, the USDA released its latest WIC program reach coverage report. Using data from 2020, USDA estimated nationally that WIC serves 50% of its eligible population in 2020, while California served 65% of its eligible population. No other state has a higher WIC coverage rate or higher number of WIC participants than California.

Note that in this latest report from USDA, USDA made modifications to their methodology so they changed their estimates from prior years and will update language accordingly in the May revision. At the onset of the pandemic, California and other states experienced an increase in WIC participation, particularly in children, due in part to economic hardships as well as changes in WIC program operations. Nationally, the higher level of participation has not been maintained, but it has in California.

From early 2020 to later in 2022, California has seen an increase in all participant categories, women, infants, and children, while the rest of the country has had increases in children but recent decreases in women and infants. The federal pandemic flexibilities have had significant positive impact on the WIC program by introducing changes in program operations and leading to broader efforts by USDA to modernize the program. Prior to the pandemic, the National Academies of Science, Engineering, and Medicine made recommendations to USDA to change the food packages, the foods that WIC authorizes.

USDA implemented a component of these recommendations in summer of 2020 by increasing the monthly benefits for fruits and vegetables. Since then, the increase has been tied to the federal budget bill and has been approved with each budget. In November of 2020, USDA released proposed regulations that would make the fruits and vegetables benefit permanent. And for context, prior to this change, a child received $9 per month for fruits and vegetables, and a pregnant or postpartum woman would have received $11.

Now, with this change, women, postpartum or pregnant women receive either $44 or $49. So quite a significant increase. And to tag on to what Dr. Aragon said, it's really nice to be able to make the healthy choice, the easy choice in this area. Lastly, USDA released another proposed regulation change just last month that would allow online shopping for WIC. While online shopping has not been possible for WIC during the pandemic, USDA is aware of the high level of interest from families and WIC partners.

And so we're very pleased to see this proposal. And finally, flexibilities permit remote appointments, and USDA has recently approved for states to continue remote appointments and flexibilities through at least September of 2026. And so indicating again that USDA's commitment to enhancing accessibility and convenience for WIC participants. Thank you.

Department of Finance.

Nick Mills Department of Finance, nothing further to add.

Will Owens LAO, no comments at this time.

Bring it up to the dais to see if there's any member questions. I'll begin. You stated that some of the flexibilities have been quite helpful. Can you go through which flexibilities will be discontinued?

LAO?

So right now, there's nothing that is being discontinued just yet. With the end of the public health emergency, the USDA's flexibilities continue through this summer and through ARPA authority, USDA is able to continue those. And so they have notified states that we can opt-in to continue those flexibilities, and we'll be doing that. So there's nothing on that front that's ending anytime soon.

Excellent. With that, I will thank very much this panel. And since we moved issues 24 through 30 to the nondiscusion, that was our last issue and panel for today. And with that, we will now move on to public comment. We will welcome public comment on all 30 issues that are on today's agenda, but ask you to keep your comments to these issues only.

We will begin public comment with individuals who are here in the hearing room, and then we will go to the phone lines as a reminder, the phone number and access code are on the first page of our agenda on the Subcommittee's website and should also be appearing on your screen if you are watching the live stream. The phone number is 877-692-8957 with the access code 131-5126 with that, let's begin with public comment. Thank you, Mr.

Chair Members. Doug Subbers, on behalf of the California Professional Firefighters, CPF represents nearly 35,000. Do you want me to.

Yeah, that works. Thank you, Mr. Chair Members. Doug Subers on behalf of the California Professional Firefighters, CPF represents nearly 35,000 professional firefighters and emergency medical services personnel statewide. We're pleased to be here in strong support of the trailer bill language. And under issue number six, I think just to echo some of the comments earlier, we do think removing the physician requirement from the Director of the Emergency Medical Services Authority will expand the pool of available candidates to be considered.

And also importantly, the proposed trailer language includes a new position of a Chief Medical Officer to ensure that medical oversight continues to be an important role of the executive team at the authority. So for those reasons, we urge your support when it comes before you. Thank you.

Thank you.

Michelle Gibbons at the County Health Executives Association of California. Staying on topic of issue six, CHIaC has taken a support, if amended, position. We also agree that removing the physician requirement for the director will diversify the pool of candidates, especially thinking about how minority populations are underrepresented in the medical community. We think that this would bring an opportunity for diversity. However, we do want to make sure that there is physician oversight over the EMS system at the state level.

And while we understand that that's the intent of creating the Chief Medical Officer position in statute, there are a lot of references to the Director of EMSA having that medical oversight over the system because they're currently a physician. So we would like those references and statute moved from the Director over to the Chief Medical Officer. We also would hope that the director have some experience in EMS health, public health backgrounds as well.

On issue 11, related to information technology and the modernization, CHIAC would just ask that the state continues to remember that local health departments often have to integrate and interact with the systems that the state is doing, and we would ask for the state to continue to look holistically to some of the questions that Dr. Wood was asking.

We have a lot of systems at the state level, and as we are undertaking this development to really streamline systems and renew systems and all of that, we would just hope that we would take a big look and map it out and then make sure that any changes really are supported both at the state and local level. Thank you.

Thank you.

Good afternoon, Mr. Chair and Members. Jolie Onodera, with the California State Association of Counties here on behalf of all 58 counties. On issue 13, would like to say the CSEC does appreciate the ongoing funding for public health infrastructure that was approved in last year's budget is maintained. We are disappointed, however, by the proposal in issue number 13, or, excuse me, issue 12, to reduce investments in public health workforce development by nearly $50 million at a time when healthcare workforce challenges continue to rise. We therefore would strongly support the staff recommendation, urging the Administration to withdraw that proposal for a $49.8 million reduction. Thank you.

Thank you.

Good afternoon. Chair and members of the committee, Isabella Argueta with the Health Officers Association of California, which represents the physician health officers in California's city and county jurisdictions. I'm here today to request that the Committee reject the governor's proposal to cut one time funding enacted in last year's budget to help support the public health workforce.

To add to what my colleagues have said, one of the training and development programs that would be impacted is the Public Health Lab Aspire Program, which addresses the severe shortage of trained and qualified public health laboratory directors. Labs are essential to the core functions of public health and are charged with disease surveillance and diagnosis, monitoring, the safety of drinking water and food supplies, and environmental infector testing.

These labs require specialized staff that have expertise in the needs of each of your districts and vary from lab to lab. Even as California's population has increased, the number of local labs has decreased. With 11 local labs closing since 1999, mostly due to a lack of qualified staff. Cutting this funding will leave Californians unprepared and vulnerable to the next pandemic. We look forward to working with you and ensuring that Californians receive a robust, well funded public health system that saves lives. Thank you.

Thank you.

Mr. Chair and members, Betsy Armstrong with the County Health Executives Association. But here today, on behalf of the EMS administrators of California, on issue six, the EMSA Director position, I would echo the comments of my Boss, but the EMS administrators, supported in concept, they've submitted proposed amendments to the statute for your consideration. Would hope that you would look at that as well. Thank you.

Thank you. Seeing no further public comment in person, we will now transition to the phone lines operators. We're ready to begin public comment on the phones when you are ready.

Thank you, Mr. Chair. For those of you who wish to make a comment, please press one, then zero. Press one, then zero only once. Pressing one, then zero. Second time will remove you from the queue. We will now go to line 18.

Good afternoon, Mr. Chairman, Members. Nicole Wordelman, on behalf of the Orange County Board of Supervisors, requesting that the legislature reject cuts to the public health workforce training funding. Like other counties, Orange County faces significant workforce challenges even as California continues to regain most of those nonagraculture jobs lost due to the COVID-19 pandemic. Workforce challenges are particularly acute in our health and human services agencies and therefore we ask that you retain the funding as part of the 2023-24 Budget act. Thank you.

Thank you.

Line 41. Your line is now open.

Thank you. Mr. Chair and Members Vanessa Cajina, on behalf of Mosquito and Vector Control Association of California, due to today's discussion on issue 11, I just wanted to chime in briefly and say that we greatly appreciate the seriousness that Assemblyman Wood has provided the looming threat of local transmission of mosquito borne illness, and his budget proposals support local mosquito control agencies using extraordinary resources to combat invasive mosquitoes.

We appreciate CDPH's partnership in elevating this issue and their partnership in tracking the spread and spread of local mosquito borne illness transition and look forward to further conversations on database management. Mr. Bailey, thank you.

Thank you.

Line 30.

Excellent. Well, I was actually anticipating talking about a couple of different items, but one of them seemed to just vanish, item number 16. So I'm still trying to get into the sort of culture of these hearings because I'm a little bit new to the legislature. So I guess what I can say for now is that I hear this sort of impulse to cut what I heard was nearly $50 million from these public health workforce positions while at the same time, by your own numbers, it sounds like one of your experts revealed that California lost 75 public health doctors and directors.

So just as an example of one of the situations that took place in the pandemic, and I used the word pandemic in quotes, I'm thinking of the public health Doctor, Amy Sisson, who left Placer county largely because Placer county ended the emergency. And she didn't really like that. So she went to Yolo County because Yolo County stayed, you know, on the COVID protocol, know, kept things locked down nice and tight.

So not to wax and wane about bygones, but it comes to my attention that maybe you lawmakers could start to connect the .s on some of this. If you're not able to retain and attract public health doctors and directors, is it possible that there's maybe a reason as to why not?

Is it possible that the public pressure felt by these individuals because Californians are not and have not been in support of these lockdowns might have something to do with the lack of being able to retain and even fill these positions? So, I mean, that's one of the things that comes to my mind from this hearing in terms of the topics that are apparently on the green light list that we are being permitted to speak about.

But again, my keen interest and the interest of many other California was item number 16. So I'm still trying to figure out where that went, why it wasn't discussed when it's coming back. But I could continue to go on since you're letting me speak. What I've also heard in this hearing is more fear mongering. You want us to be afraid. You're already talking about the next pandemic. You've mentioned Ebola, you've talked about mosquitoes.

And it's become pretty clear to many of us in California that your posture is just, that it's of fear mongering and coercion and removing our rights from us, just like this corrupt legislature has done for the last two plus years, being three plus years that we're now officially, I guess, out of the state of emergency. But you folks pandered to this governor for three years, even as one of your lawmakers sits up there talking about what rights you're going to take from us next.

We're going to move on to line 44. Line 44, your line is now open.

Operator, can I ask you not.

Just a second, operator. I'd ask you not to cut off those who are providing public comment. I'm happy to sit and receive the public comment. I would invite those who are commenting to also feel free to submit written testimony if you're unable to provide your comments today. And finally, I'll just remind that you can comment on any of the issues that are in the agenda today, whether they were discussed or on the nondiscusion portion of the agenda.

Thank you, Mr. Chair. The previous speaker is free to queue back up again by pressing one, then zero again. Line 44, your line is now open.

Good evening. Ronald Coleman Baeza with the California Pan-Ethic Health Network. While we understand legislators must make incredibly difficult decisions this year, given the condition of our state's fiscal outlook, we urge the legislature to once again prioritize the California Health Equity and Racial Justice Fund. As you know, it wasn't in the Governor's Budget, so is not part of the discussion today.

But it is a critical missing piece to ensuring a comprehensive public health infrastructure to address both social determinants of health, to further health and racial equity. In order to improve community health outcomes. We urged the legislature to create a pilot program and fund the health Equity and Racial Justice Fund, initially with $50 million over two years.

Additionally, we urged the legislature to reject the governor's proposed $49.8 million in cuts to public hero workforce development and training programs and to sustain the ongoing $200 million for public health infrastructure. But a reminder that the community investments matter, too. Thank you.

Thank you.

Line 39.

Good afternoon. My name is Rachel Bogwitt, and I'm the Deputy Director at the California alliance of Academics and Communities for Public Health Equity, or the alliance at the Public Health Institute. I'm here. We bring together and represent academic experts from University public health schools and programs across California in partnership with community public health leaders and practitioners. I'm here about issues 12 and 13. The alliance strongly opposes the public health workforce cuts proposed in the Governor's Budget.

We urge the Legislature to lead the state towards a different solution that doesn't include those 49.8 cuts. We need a strong, diverse, representative public health workforce and pipeline programs like those impacted are critical to building and sustaining that workforce. Hearing the testimony that the budget cuts would lead to many of these programs ending at the end of the year is deeply disturbing, and it's the opposite of the direction California needs to go.

In addition, California also must strengthen the community based public health infrastructure, and that means investing in community health workers, Permaturis, peer specialists and more. We know that these folks are the people who are reaching many of our hardest to reach communities, black, brown, rural and other underserved groups. And by investing, we mean pipeline programs, but also valuing these workers just as highly as we value traditional health professions with salary equity, pathways to leadership and development, worker protections and more. Thank you.

Thank you. Next caller, please.

Line 38. Your line is now open.

Hi, I'm calling for issue number seven. My name is Scott Suckow. I'm the Executive Director of the Liver Coalition here in San Diego, California. And on behalf of the Liver Coalition, I'm calling in support of the $11 million funding request for adults with sickle cell. Sickle cell disease or its treatments, including blood transfusions, can increase the risk of liver damage from iron overload and hepatitis.

The Liver coalition thanks the CDPH for their previous support and dedication of the $5 million for the clinics in the last budget cycle, and we are in support of the additional 11 million in sustained funding to ensure networking. California for sickle cell care can continue improving health and outcomes for adults living with sickle cell disease by ensuring its long term standing within CalAIM under DHCs. Thank you for allowing me the space to speak.

Thank you. Next caller, please.

Line 43, your line is now open.

Hello chair and members, this is Autumn Ogden-Smith with the American Cancer Society Cancer Action Network, and I wanted to speak on issue number 22 regarding the California Cancer registry. As you heard, the CCR is a vast repository of cancer data that provides vital information to public health officers and researchers. With this data, it is possible to determine cancer risk factors and study groupings of cancers and communities.

With proper funding, we will be able to use this data in real time to connect cancer patients with clinical trials. The CCR is the top in the nation and used by researchers worldwide. However, in order for our registry to survive and continue, we must ensure that it is fully funded. Thank you so much.

Thank you. Next caller, please.

Line 48, your line is now open.

Thank you. Chair and members of the committee, my name is Matthew Marsom with the Public Health Institute. I'm here to speak about both issue 42, sorry, issue 22 and issue 12. First, regarding the cancer registry, I echoed the remarks already been made on behalf of Public Health Institute. We are in strong support of protecting and maintaining funding for the cancer registry. I thought appreciate greatly the comments made by members of the committee earlier during the item when it was heard.

I would just echo that the flat funding that the cancer registry has experienced now for a decade has continued to exacerbate the impact and mean that the local regions and the state are not able to meet their cost share requirements. And we need to do everything we can to protect the cancer registry. So we look forward to working with members and also the department and the administration to protect money for the cancer registry.

Regarding issue 12, I also join others today and urge the Legislature to reject the cuts that would eliminate the investments in public health workforce. The colleagues and advocates spoke earlier about the need to protect funding for governmental public health. I echo that it's so important, but also emphasize the need to continue investments in community public health. We are all public health, and as we've seen through the pandemic, the role that community workforce play in reaching the hardly reached and the harder to reach communities is vital.

And so ensuring ongoing investments to community based organizations for public health workforce is critical. And that's why we're in strong support for the health equity and Racial Justice Fund. Thank you very much for the opportunity to speak.

Thank you. Next caller, please.

Line 35, your line is now open.

Good afternoon chair and members. Kathleen Soriano, the University of Southern California. We appreciate the opportunity to comment on issue 22. On the California Cancer Registry. I'd like to echo the comments made by my colleagues at the American Cancer Society Cancer Action Network and the Public Health Institute. USC is one of the three regional registries that work directly with the CCR, providing critical support on local instances of disease.

USC supports all efforts to ongoing support from the state General Fund to protect the registry and respectfully disagrees with any proposed cuts. Funding will protect and strengthen the cancer registry and help maintain ongoing federal funding that's vital to the program's ongoing survival. USC looks forward to continuing working with the legislature, PDPH and the Administration on this important issue. Thank you.

Thank you. Next caller, please.

Line 13. Your line is now open.

Thank you chair and members, I'm Meron Agonafer with policy and legislative affair manager, the California Black Health Network, calling to speak on two issues. On behalf of the CBHN, I'm calling in support of the $11 million funding request for clinics for adults with sickle cell disease. We would like to thank CDPH for providing $5 million last year to sustain the innovative network and support the $11 million to transition networking in California for sickle cell care into DHCS under calm.

This network directly address health inequities by providing more access to comprehensive care for adults with sickle cell disease. Regarding the Health Equity and Racial Justice Fund, on behalf of CBHN, I'm calling in support of establishing a pilot project of 50 million over two years to create the health and Equity Racial Justice Fund to directly fund community based organizations, clinics and tribal organizations. This is part of a comprehensive approach to address the social determinants of health.

Local leaders know the needs at the neighborhood level that may not show up in the state, county or hospital needs assessment CBHN, urge your support. Thank you for your time.

Thank you, operator. Before we go to our next call, we have a few more public comments who are here in the hearing room. We're going to take those next and then we will return to public comment on the phone.

Good afternoon. I'm Mary Brown. I'm the President and CEO of the Sickle Cell Disease foundation and co lead with Dr. Diane for networking Sickle cell care. Thank you for your funding support over the past few years. We hope that you will continue to let us maintain and grow these clinics. Thank you so much.

Thank you.

Thank you for allowing us to testify on behalf of the 12 clinics that have been developed. Thanks to the funding provided by the state back in 2019, we're already demonstrating a significant impact on life expectancy for sickle cell. Improved care, quality workforce expansion and education of our ERs and hospitalization with significant cost savings that have been demonstrated by the CDC already.

So we thank you for your willingness to maintain funding this year and help us transition to CalAIM, the path cited program, which is what we're applying for now. So thank you very much.

Thank you, operator. We will now return back to the phone lines for public comment.

Thank you, Mr. Chair. And as a reminder, if you wish to speak, please press one than zero. Pressing one than zero a second time will remove you from the queue. Press 1 and 0 only once. We're going to go to line 36 there.

My name is Mike, one of the people, the State of California, and you guys are spending a lot of money. And then I find it interesting that the doctors for the California Department of Public Health have been stepping down and not being replaced.

I couldn't think of anything that's better based on what happened in Santa Clara County with Sarah Cody, the health Director here, and over in Santa Cruz County with Gail Newell. These guys are tyrants. And you guys funding tyrants. The people don't appreciate it being one of the people. I can tell you that's the truth. And asking for more money for more tyrants. I agree that we shouldn't have that money. So way to go on that one.

And as far as the mosquitoes go, how about not releasing genetically modified animals into the freaking atmosphere without letting people know that everything could change and you might be getting some kind of diseases that you have no idea about because nobody understands any of that technology other than that. Have a fabulous day. Keep doing what you're doing. That's cutting the budget all the way down to zero. Way to go.

Thank you. Next caller, please.

Line 49, your line is now open.

Good afternoon, committee chair and members. My name is Ana Vasudeo and I'm calling on behalf of the Public Health Institute and in support of the creation of a health equity and Racial Justice Fund. Along with our partners, which you have heard from today, I am joined by over 200 community organizations across the state that share our desire to create this fund.

We call upon the committee to create the fund in law this year, especially given the conversations you've had today regarding racism as a public health crisis and the importance of investing in prevention. With the end of programs such as the Supplemental Nutrition Assistance program, we expect to see health disparities persist and worsen for communities of color. We need to recognize and support community organizations as part of our public health system.

CBOs can better address issues that drive illness, like healthy food access, vaccine hesitancy or community violence. Recognizing the fiscal challenges this year, we request a smaller amount of $50 million over two years for a pilot effort that will support CBOs, clinics and tribal organizations to address the social determinants of health and systemic racism. PHI also supports funding for the California camp late priorities.

We recognize the difficult budgetary context that you find yourselves in, but ask that this be the year of the establishment of the Health Equity and Racial Justice Fund. Our most vulnerable communities are counting on you. Thank you so much.

Thank you. Next caller, please.

And this is the final call. If anyone has a comment, please press one, then zero. Mr. Chair, no one else has signaled that they wish to speak.

Thank you, Mr. Operator. I will take that as the conclusion of public comment for today. I will take a moment to thank the administration, Dr. Aragon, the Department of Finance, LAO, all of the stakeholders and panelists, our colleagues who was here. But most importantly, I want to thank the public for participating and making our process better.

Finally, I would like to thank the sergeants and the tech as well before we close today's hearing out and would like to appreciate Andrea Marcolis for creating another wonderful agenda and creating the discussion today. We are adjourned for the night. Have a good night.