Assembly Budget Subcommittee No. 1 on Health

[Roll call]

Okay Today we will be addressing a variety of different issues within the health budget, and we will start with the discussion on the California Health Benefit Exchange. Today on the panel we will have Katie Ravel from Covered California, Joseph Donaldson from the Department of Finance, Albert Pineda from the Department of Finance, and Ryan Miller from the Legislative Analyst's Office. You may begin.

Good afternoon, Dr. Weber and Assemblymember Bonta. I'm Katie Ravel. I'm the Director of Policy Eligibility and Research at Covered California. I'm happy to be with you this afternoon. And I'm ready to provide provide a brief overview of Covered California and our affordability programs and then answer any questions you have. The Affordable Care Act, which was passed in 2010, dramatically changed the individual health insurance market.

A key component of the Affordable Care Act was the creation of health benefit exchanges that offer comprehensive health plans with income based financial help to lower premiums and out of pocket costs for individuals who don't have coverage through their employer, Medicaid or Medicare, and Covered California's our state's health benefit exchange.

Our mission is to increase the number of insured Californians, improve healthcare quality, lower costs, and reduce disparities through our innovative competitive marketplace that empowers consumers to choose the health plan and providers that give them the best value. Covered California contracts with 12 health insurance companies throughout the state. Our members choose from several coverage options that vary in the amount of monthly payments, premium, and the cost sharing that they pay.

Over the last five years, California and federal action has built on the foundation of the Affordable Care Act to provide more support for our enrollees to afford their coverage. Federal action includes enhanced premium subsidies, which were authorized by the American Rescue Plan and extended through 2025 by the Inflation Reduction Act of 2022. California has taken several key actions on affordability. In 2020, we implemented a nation leading premium subsidy program through which middle income Californians were able to access premium assistance for the first time.

And just last year, we implemented subsidies to reduce out of pocket costs, and we implemented the Healthcare for Striking Workers Program. In particular, the Budget Act of 2023 authorized Covered California to spend $82.5 million to lower out of pocket costs for Covered California enrollees. We call this the "California Cost Sharing Reduction Program". For benefit year 2025, we use the funding to eliminate deductibles and lower costs for key services like primary care, outpatient, mental health, and prescription drugs for our lowest income enrollees.

With the implementation of this program, Covered California was able to offer the highest level of affordability, of financial assistance in our history. Currently, more than 700,000 enrollees are receiving these new plans, plans with lower out of pocket costs and no deductibles. The record affordability this year pushed our sign ups to an all time high. As of January 31, the end of our open enrollment period, over 1.78 million Californians had selected a Covered California health plan for 2024.

New signups increased about 16% over 2023, exceeding 300,000 new enrollees, the highest level for us since 2020. Before I stop for questions, I'm pleased to say that we're now working on the design of the 2025 cost sharing program. The governor's fiscal year 24-25 budget includes an appropriation of 165 million for the program.

With this higher funding level, the 2025 program will continue to support those who are eligible for the program today and significantly expand eligibility above our current income cap at 250 of the federal poverty level. We're doing our final work now on modeling, and we'll have a design for our Covered California board to adopt later this spring. With that, I'm happy to stop and take any questions you have about our program.

Thank you. I'll first see if Assemblymember Bonta has any questions.

Thank you. I did have some questions about the reservation of the $2 million for the strike fund, essentially. I know that there was a legislative proposal to increase that fund from 2 million to 20 million and wanted to just understand the implications of that within the context. So just specifically, can you provide an update on the strike fund that was funded last year?

I can. I'll provide an operational update and then maybe Department of Finance would like to add. We had funding for the first time in July of 2023, and the program actually started in July of 2023. There was a small Teamster strike, so those were our first enrollees under the program. We provided-- Between July and December, we provided about 75 Californians coverage through the program. They were each enrolled for about two months, and our expenditures were a little under $40,000 for the program.

That sounds low, but that the program is on top of federal subsidies, which will often pay much of the premium costs for those members. So then the state subsidy sits on top of that.

So if there was kind of a considerable strike last year. So, for instance, the Teamsters, if they-- or last year in that strike, do you have an estimate of how much it would have cost if the strike had gone on beyond one month? Given the size of the striking workforce.

Yeah. The UPS strike would have been significant. I don't have off of the top of my head what our modeling was if that strike had resulted in workers losing their health coverage.

And then related to that, the Healthcare Affordability Reserve Fund, can DOF provide an estimate of how much is in that fund currently?

In the Reserve, there's $124 million. Sorry, I'll repeat-- Department of Finance.

And how is that fund funded currently?

So it's funded through the individual state mandate, or the ISRP, which is a penalty that individuals that have elected not to have health care pay.

And what programs are paid for from this fund?

The cost sharing program is being paid from that fund, as well as the Healthcare for Striking Workers program.

Okay. What would happen in the event that we expended the $2 million in an additional strike?

If we expended the program, Covered California would have to stop providing those subsidies. Any enrollee who was eligible to enroll in Covered California, generally having lost their employer coverage, could still receive federal premium subsidies and cost sharing that they were eligible for based on their income, but we wouldn't be able to provide that additional state premium subsidy.

Thank you.

Just a few more questions. So there is a potential that the federal premium tax credit will expire in 2025. How are you envisioning that to possibly impact your caseload?

We think the impacts would be quite significant. We thought it could have been in the neighborhood of over 150,000 enrollees when we faced this before in 2022. We'll be doing updated modeling, probably later in the fall once we know our 2025 rates, and we'll be able to update those numbers. Our caseload has grown significantly since then, so we will have updated numbers available. We'll be able to provide technology assistance on the total size of the enhanced federal subsidies and then any enrollment impacts.

Okay. And have you noticed that with our Medi-Cal redetermination deadline, has that impacted your process any way?

We were fairly well prepared for that. We were quite fortunate in California to be able to implement such Senator Hurtado's SB 260 from 2019. That bill gives us the ability to automatically select a plan for people who lose Medi-Cal. We implemented that with the start of the redeterminations in May, and we've seen good early success. Every month, thousands of people transition to our coverage from Medi-Cal under the program. Our operations have been stable.

Both our website and our call center and consumers have reported generally a positive experience, feeling like the transition has been smooth. So we've been very pleased so far. And that's a program that will go on beyond the unwind period, and it will be the norm for us transitioning individuals from Medi-Cal.

Well, thank you very much. If there's nothing else, we will move to our second panel. And we will take all public comments at the end. This will review our Department of Healthcare Access and Information.

Madam Chair, Assemblymember Bonta. My name is Scott Christman. I'm the Chief Deputy Director for the Department of Health Care Access and Information, or HCAI. I'll provide an overview of the department's programs and budget and a brief update on the health care payments data program.

I'm joined by two deputy directors to present updates as well on the Office of Health Care Affordability, the CalRx initiatives, as well as an update on the health workforce development programs as indicated in the agenda. The Department of Health Care Access and Information was recast from the Office of Statewide Health Planning and Development, or OSHPD, in 2021, in recognition of our expanding program portfolio.

Our mission is to expand access to quality, affordable healthcare for all Californians through resilient health facilities, actionable information, and the health workforce each community needs. The Department includes five program areas that I'll touch on: facilities, financing, workforce data, and affordability. So first, HCAI serves as the Building Department in California for hospitals and skilled nursing facilities, monitoring the construction, renovation seismic safety of these facilities.

Our primary goal is to promote patient safety by ensuring that each facility remains functional in the event of a natural disaster, including major earthquakes. In terms of financing, HCAI administers the Cal Mortgage Loan Insurance Program, offering loan insurance to nonprofit and public health facilities for the development and expansion of healthcare services throughout California. We also implemented the distressed hospital loan program last year, which was discussed actually in a previous oversight hearing this the cycle.

We also administer the new Small and Rural Hospital Relief Program, which provides grants to small, rural and critical access hospitals for seismic safety compliance projects. In terms of workforce, HCAI manages a very broad, expanding portfolio of health workforce development programs with the goals of building a workforce that one, reflects California's racial and linguistic diversity, two, serves medically underserved areas, and three, serves Medi-Cal members across California.

These programs specifically support delivering primary care, behavioral health, and oral health, and through these programs we apply a range of strategies that include direct grant funding to medical schools, nursing programs and other healthcare training institutions, scholarships and loan repayments to students and health professionals who agree to provide patient care in medically underserved areas, and pipeline programs that introduce health professions to youth from underrepresented communities. HCAI also funds several important programs supporting healthcare providers that ensure Californians have access to reproductive health, including abortion services.

Our fifth and latest program area focuses squarely on healthcare affordability, including three parts, the Office of Health Care Affordability and CalRx Pharmacy Programs, which you'll hear more about, and the Hospital Fair Billing Program. So Vishal Pagani will present updates on OHCA and CalRx in the next item. But I'll just add that this year ,new to HCAI, we took over enforcement of the Hospital Fair Billing Act, which imposes rules on hospital billing practices for uninsured and underinsured patients.

So we now accept complaints directly from consumers about hospital bills and review those to determine if a hospital followed their own discount and charity care policies. We also check to confirm those policies comply with legal requirements and that hospitals are conforming to those requirements. In terms of budget at HCAI, our current year budget is $1.2 billion and our proposed budget for 24-25 is 523 million.

Many of these funds include multi-year authority, such that we continue to spend down some prior year funding. The proposed budget reflects a reduction of $716 million compared to the current year budget of 1.2 billion, but the current year budget includes carryover from fiscal year 22-23 of approximately $823 million, $753 million of that as general fund.

So if we refer to the original current year budget of 667 million, the actual difference year over is $143 million, mostly due to delays in health workforce funding from the last cycle. HCAI's proposed budget also reflects delays in health workforce management program funding of $70 million for nursing, $70.1 million for social work, and 189.4 million in various behavioral health programs. Funding from the 23-24 budget for a total of 329.5 million in proposed delays, which Libby Abbott will cover in more detail in her presentation.

We are requesting position authority only, not funding, for 19 positions in the proposed budget, which would bring the Department to 748 authorized positions in the budget year. I'd be glad to answer any questions or move to the update on the health payments data program.

You can move to the update. Thank you.

Thank you. Okay. The Healthcare Payments Database, or HPD, is California's all payer claims database. The information from the HPD is intended to support greater healthcare cost transparency and used to inform policy decisions regarding the provision of quality healthcare and to reduce healthcare costs and disparities broadly.

More specifically, the HPD is a large research database made up of healthcare administrative data, primarily of healthcare claims and encounter data, including the claims that providers submit to health plans for payment and the encounters for services provided under a managed care arrangement, which include health plans, insurers, public self insured organizations, Medi-Cal, and Medicare. The database includes patient characteristics, procedures and services information, provider information, cost information, and more. These data can be used to understand trends and variations in healthcare costs, utilization, quality and equity.

Implementation of the database was authorized by the budget adopted in 2020. It included a one time $60 million general fund appropriation authorized through fiscal year 24-25 coming up. I'm pleased to report the database was successfully implemented coming online last year, July 23. As specified in the statute. HCAI has since released two public analytic reports and the datasets associated with that and is designing policies and procedures now for controlled access to non-public data by request from the research community beginning later this year.

In March of this year, HCAI submitted a report to the Legislature that details the status of the database currently and specifically evaluating the data quality and completeness. The report concludes that the HPD data is comparable to other claims databases in other states and suitable to support a number of use cases for research and analysis.

Additionally, HPD information is used to support the Office of Health Care Affordability, which you'll hear more about necessary for OHCA to fulfill fully assess total healthcare expenses, expenditures, identify cost drivers, and to perform targeted analyses by population, geography and healthcare sector. A question in the agenda was, has the healthcare payments data program dataset been used to analyze healthcare costs?

Yes. The HPD provides a critical opportunity to analyze healthcare costs in the state. Our HPD Stakeholder Advisory Committee has prioritized two areas in particular for public reporting on healthcare costs. This includes prescription drugs and hospital costs. So HCAI is now in the process of developing the first prescription drug cost report, which should be released soon and has set hospital costs as a priority for future public reporting.

Additionally, OHCA has begun to assess HPD data that can support their affordability and spending growth analysis functions. For example, attributing claims and spending to hospitals and using claims data to understand healthcare utilization by region in California to support OHCA's equity work. Additionally, the CalRx program is also evaluating HPD data to understand prescription drug distribution patterns that can help the program maximize cost savings for consumers.

So with that, be happy to answer any questions on the overview or move us to the next item on the agenda, which would be updates on the Office of Health Care Affordability and the CalRx initiatives.

Let's go ahead and do that.

Very good. I'm going to turn it over to Vishaal Pegany, our Deputy Director.

Good afternoon, Members of the Committee. I'm Vishaal Pegany, Deputy Director for the Office of Healthcare Affordability at HCAI. I'll first provide an update on the progress of implementing the Office of Health Care Affordability, or OHCA. OHCA was established in the 2022-23 budget to address the crushing costs consumers face in paying for healthcare premiums and services.

We know that more than half of California consumers go without healthcare services due to cost and face worse health conditions as a result, and those impacts are worse for black, Latin and low income Californians. In response, the Governor and Legislature partnered to create OHCA. OHCA has three main efforts. First is slowing healthcare spending growth, the second is to promote high value system performance, and the third is assessing market consolidation.

We have had our first full year of engagement with healthcare stakeholders, sibling state departments and the public, and I'm pleased to give an update on our progress. The Health Care Affordability Board was appointed and began meeting in March, last March. Our board meets monthly, with their last meeting occurring a few weeks ago, and we have very robust stakeholder engagement.

On establishing a spending target, OHCA and the Health Care Affordability are working towards the June 1 statutory requirement to set a statewide spending target that establishes an acceptable annual rate of growth for per capita healthcare spending. In January, OHCA recommended to the board a 3% statewide spending target for calendar years 2025 through 2029. This recommendation was based on the 20 year average annual change in median household income over the 20 year period from 2002 to 2022. There are several reasons for tying the target to historical median household income growth.

First, basing the target on this measure adheres to the statutes requirement to promote the goal of improved consumer affordability. This is also in alignment with the board's preference for using a consumer centric economic indicator. Most importantly, tying to a historical median household income growth signals that healthcare spending should not grow faster than the income of California's families. This recommendation places California on the path of a more sustainable, affordable and equitable health care system, slowing the trajectory of healthcare spending growth and improving affordability for Californians.

I'll now move on to providing an update on our total healthcare spending data collection efforts. OHCA has finalized emergency regulations, establishing requirements for payers to submit data on total healthcare expenditures by September 1 of 2024 and annually thereafter. These regulations facilitate the data collection necessary to measure total healthcare expenditures. OHCA will publish a baseline healthcare spending report in 2025. Based on the enabling statute, spending in calendar year 2026 will be subject to progressive enforcement, which includes engaging in technical assistance with entities that exceeded the target, compelling public testimony at a public meeting of the board, implementing performance improvement plans and, as a last resort, assess financial penalties.

Moving on to OHCA's health system performance activities. To ensure a balanced approach to slowing spending growth, OHCA is promoting high value system performance through creating alternative payment model standards, adopting alternative payment adoption goals or value based payment adoption goals, and setting a primary care investment benchmark informed by a multi stakeholder investment and payment workgroup.

OHCA is also laying the groundwork to fulfill its requirements to advance workforce stability, to adopt a benchmark for spending on behavioral health, and to also measure a set of equity and quality metrics alongside spending performance. And going to the third prong of OHCA's efforts, market consolidation. Because healthcare consolidation is a major contributor to healthcare costs, the third area OHCA has authority over is healthcare market oversight.

In this area, OHCA has issued regulations implementing its cost and market impact review program and developed a web portal for healthcare entities to submit notices of proposed mergers and acquisitions. As of January 1, 2024 healthcare entities are required to provide OHCA with 90 days notice of covered transactions such as mergers, acquisitions and corporate affiliations that are expected to close on or after April 1, 2024.

Through its review of transactions, OHCA will monitor the impact of market consolidation and will evaluate and review prospective transactions that could affect affordability, access, equity and care in California's healthcare market and publicly report on these transactions. OHCA's review will fill a gap in the oversight of transactions that are currently not reviewed by other regulators, such as the Attorney General or other state agencies. I'll now provide an update on the CalRx program.

I'd first note that the agenda includes our technical adjustment BCP, which would provide position authority using existing budget resources. I'll now provide updates on implementing the CalRx Biosimilar Insulin Initiative and the CalRx Naloxone Access Initiative. First, biosimilar insulin as many of you are aware, in February 2023, HCAI initiated a contract with Civica Rx, a nonprofit drug company, for the development of biosimilar insulins for the three most popular forms: Aspart, Lispro and Glargine. Civica is advancing on its development efforts and maintains close communications with the FDA.

They do not, at this time, have a specific timeframe for approval. In his role as a Civica Foundation Board Member, Health and Human Services Secretary Dr. Mark Ghaly will continue to work with and help drive our Civica partners to make CalRx insulins available as soon as possible. Civica is making enhancements to its Petersburg, Virginia team to help further these efforts for drug development.

Regarding the Governor's Budget deferral of the 50 million for the manufacturing facility, we note that this component of the initiative entails complex planning with active collaboration among HCAI, Civica and the Governor's Office of Business and Economic Development. It is anticipated to extend beyond the current fiscal year due to its multifaceted nature that includes site selection, assessing water and energy needs, and ensuring access to skilled labor.

This project will be necessary when Civica needs to expand beyond its initial overseas supplier for active drug substance, at which time the California based manufacturing facility would be the domestic source for active drug substance. Efforts towards getting the product in market or commercialization is also in progress, with Civica focusing on discussions with health plans and PBM or pharmacy benefit manager entities to achieve preferred formulary status for the CalRx branded insulin products once they're approved by the FDA.

I'll now cover the CalRx Naloxone Access Initiative. Regarding our work to bring a low cost, over-the-counter version of naloxone, we have been having positive, ongoing discussions with multiple vendors. We are confident we will be able to procure an over-the-counter version of Naloxone at a significantly reduced price than the current public interest price that is available to the Department of Healthcare Services Naloxone Distribution Program.

Our goal is to have a partnership agreement in place by summer and CalRx-branded Naloxone products available for purchase by the end of the current year. That covers my overview. I'm happy to take any questions or move on to the next item.

I wanted to focus some queries around the workforce initiatives. I think one of the things that was most striking to me was that we just decided to move forward as a state with Prop 1. Everywhere you look there is a need for behavioral health workers.

We've had several hearings in terms of the need to diversify our healthcare workforce and wanted to just highlight the fact that there have been significant deferrals in spending around healthcare, workforce training and pipeline development in the governor's proposal and in your BCPs. So if you could just kind of step back into that space and give us a sense of what has been happening in terms of the overall workforce initiatives, just an update on the status of those.

And then more specifically, what would a delay in the workforce funding that has been articulated due to impact workforce training?

Yeah, Assemblymember Bonta, the next speaker, Libby Abbott, would be happy to answer those questions.

Yeah, absolutely. Can you hear me? There are a number of questions in the agenda that I can talk through. Maybe I'll start with just the first one to give you an update on some of our major initiatives. So, Libby Abbott, Deputy Director for the Office of Health Workforce Development, I'll start there and then feel free to jump in. We have quite a few questions to get through. HCAI currently implements a total of 56 programs spanning primary care, behavioral health and oral health.

In recent years, we have taken on the workforce components of several major initiatives. So in the interest of time, I won't walk you through our 56 programs, but I'll focus on two of those major initiatives.

In 2021, the Children and Youth Behavioral Health Initiative, CYBHI, was launched as part of the Master Plan for Kids Mental Health, a historic investment by the State of California that takes a whole child approach to address the factors that contribute to the mental health and well being of our children and youth.

From this package, HCAI received just over $338 million in local assistance to stand up a new type of provider, certified wellness coaches who will be a culturally diverse and representative workforce that that will support children's social and emotional development and provide appropriate referral services in settings that reach all children, including primarily schools and community based organizations. Over the last two years, HCAI has worked hard to put in the legwork to research, design and roll out this new provider type.

In February, we launched the certification platform and I'm very pleased to be able to share that as of this morning, we have California's first 48 certified wellness coaches with over 1000 additional certification accounts created and an ongoing active marketing campaign to recruit additional candidates for certification. We will soon be announcing $120 million in awards as part of our Employer Support Grant work stream, which gives county offices of education, local education agencies and community based organizations the opportunity to hire their first wellness coaches.

While the sustainable financing solution in the form of the Medi-Cal benefit is expected to come online in 2025. So that's sort of a bridging grant to generate demand and get folks online. This month, we will also launch our first scholarship cycle for students interested in becoming wellness coaches. The second initiative I'll provide a brief update on is the reproductive health initiative. In 2022, HCAI was authorized to implement $113.3 million of available funds to expand expand access to reproductive care and abortion services.

In our first two years, we've administered 44 million, or 39% of those funds to expand the workforce needed to provide reproductive health and abortion services, secure physical infrastructure and provide financial support both to facilities that are providing care to low income patients and to individuals who have traveled to and within California to receive critical reproductive healthcare.

Some of our specific results thus far include that we have provided financial support to 1074 individuals seeking abortions, we have awarded $8 million to 21 facilities and providers to secure physical and digital infrastructure, we have provided uncompensated abortion care services in more than 40 of California's 58 counties and we have awarded 3.9 million in scholarships and loan repayment to 186 health workers who have committed to providing reproductive care and we will be awarding an additional 2.4 million to 75 additional awardees.

HCAI is also using the Reproductive Health Initiative funding to support the University of California, San Francisco to stand up the reproductive health warm line, a confidential, non-emergency call center that focuses on providing real time clinical case reproductive health and abortion education and support to clinicians in primary care settings both within and outside of California. To support the implementation of these critical initiatives and our many other health workforce development programs, HCAI has submitted a budget change proposal, alignment of health workforce development programs and staffing resources.

This BCP requests position authority for 16 positions for the Office of Health Workforce Development for fiscal year 24-25 and ongoing to implement multiple new and expanding health workforce development program programs and initiatives and would be supported by previously authorized expenditure authority. There is no additional fiscal for these positions.

The BCP is a true up for workload and we are using this to replace, contract and blanket staff and transition them to permanent state staff in order to catch up with and sustain workload associated with a significant increase in funding that we've seen over the last several years. I'm happy to pause there. I know there were several other questions in the agenda that I can address if helpful.

I have a specific question around the impact of the proposed workforce initiatives on the CHW/P/R certification program.

So those funds are not impacted by our deferrals. We maintain, I believe it's 188 million for the coming budget year. We are going through an extensive, as you heard at our last hearing on this, an extensive consultation process to make sure we use those funds wisely and in the most impactful way, and we expect that we will have a clear sense of how best to allocate those funds and how best to support statewide professional development and the option of a certificate in the coming months.

Since we're on the subject of programs, I had a conversation about this, I believe, in the last budget hearing, and I didn't really get a clear answer. So you all were allocated money for a Psychiatric Loan Repayment Program, which you chose not to implement. Why?

Albert Pineda, the Department of Finance. So I would note that this is a new program that's a work in progress administered by HCAI, on the behalf of the Department of State Hospitals.

And although a substantial amount of work had been done by HCAI to operationalize this new program. Such as develop the application process, develop eligibility criteria awards, and reporting criteria. The program funding had not gone out yet, and the Administration identified this as a proposed solution to the budget problem in order to minimize the impact of court programs.

So, unfortunately, that was the same answer we got in the last session. And so I was hoping that, you know, with HCAI here, who was placed in charge of overseeing the program, that I would get a different answer, or I would say a more thorough, in depth answer as to why this money was allocated in 2022, saying that we have issues with behavioral health, with up and down our state.

We all acknowledge the lack of providers, and this was given to you as another tool in your tool belt to get more psychiatrists into our state hospitals to really care for some of our most severe patients that have behavioral health needs. And it was not implemented. And not only was it not implemented, but now you're saying, you know, take the money back, but I guess I won't be getting an answer as to why that wasn't completely implemented.

I will go on to the Office of Healthcare Affordability. Very excited to hear about all of the things that you all are tackling. Very much looking forward to seeing how everything plays out. Was very impressed to hear, looking at different payment models, such as the value based payment. I think a lot of people have kind of talked about we need to kind of switch over to how we are paying or reimbursing providers.

One of the things that I have heard as a conern is this 3% statewide spending target, and was wondering if you all had taken into account certain issues such as inflation, such as increase in payment for workforce, and those other items, Legislature. New laws that come down that will cost health plans more money. Did you all take that into consideration when you came up with that 3% is a 3% separate.

And so as plans are explaining why they may be over 3%, those things are kind of pulled out. Can you explain that to me?

Yes, Assemblymember Weber. So the process we took was based on the statute requiring us to review economic and population-based indicators. The board early on signaled that they wanted us to focus on consumer-centric measures such as median household income. So the 3% recommendation is based on that. Having said that, we have discussed how OCA is going to progress or how OCA is going to assess performance once the data comes in and we assess how healthcare entities do against the target.

So there's several factors that have been identified by stakeholders, such as the role of technology, investments for technology, high-cost specialty drugs, and it's difficult for OCA to adjust for those factors on the front end because they don't impact everyone equally or in the same way.

So what we have said is that on the back end, what we're calling assessing performance, we would take into account additional information from the healthcare entity for reasons, reasonable explanations for why they may have exceeded the target, and we would have a conversation with them about that.

Thank you.

I just have a broader question, perhaps, and something that we could probably say of many different departments and initiatives. When there is a just on the level of kind of offering transparency and accountability.

So when there is a legislative initiative like the psychiatric loan repayment program, for instance, where it's been indicated as a priority of the Legislature, and there have been years of kind of establishing the program, and then ultimately it doesn't get established, and then we cut the funding, what is the alignment between the agency's level of accountability for implementation of legislative priorities and the process that we're going through now?

I would hate for us to be in a situation where we just kind of delay and delay and delay implementation and ultimately end up not moving forward with what we said that we were going to do. After 120 legislators voted on something, the Governor chaptered it, and it ends up being something that we all believe is going to happen for our constituents and now we're faced with making serious budget cuts.

I think that these decisions reflect the difficulty in developing a balanced budget and balancing legislative as well as administrative priorities.

Doesn't really answer my question. I'm essentially getting at the fact that we're going to be having a lot of these conversations, and I would hate for around cuts, and I would hate for the strategy to be that we delay implementation on programs that we've identified that we need and then just ultimately end up cutting them because they haven't been implemented fully.

So how can we, from an accountability standpoint, an implementation standpoint, ensure that we're actually moving forward with the programs that we fight so hard to get funded? That's still a question, hoping for a different answer that might be more specific to the question that was asked.

Hi, Jason Constantouros, Legislative Analyst Office. You know, first I want to note that, you know, there are a lot of initiatives that are being proposed for delay or reductions. It looks like you've found the page, but just so you're tracking on page eight, there is a table that summarizes all of the proposed reductions and delays in the Governor's Budget. There were additional delays that were enacted last year. That table only shows what's being proposed this year.

And, you know, I defer to the Administration to explain what's going on with that particular loan repayment program. You'll see that there actually were two loan repayment programs, one for counties and one for state hospitals. The administration's proposing to delay funding for the counties but reduce or eliminate funding for the state hospitals. So there's a difference in treatment there and just wanted to make sure that was clear. But generally, a key issue for the Legislature this year is the state's constrained budget.

And this does, I think, play a key consideration this year. The Governor's Budget and our office as well anticipate project there to be deficits in the out years. About $30 billion was sort of the last estimate. Those will get updated in a revision. When there's a proposed delay, the assumption is that, at least implicitly, is that funding will resume in 25-26. But again, if there are deficits in that year, that might be hard to do.

So this is a key sort of issue for the Legislature to grapple with, typically, you know, focusing on, you know, having a multi-year that doesn't have deficits and ensures that there's capacity, can be one tool to help ensure that the intended initiatives are, you know, being implemented and as sort of their intended.

But it is a key issue for the Legislature this year in terms of its budget capacity and, you know, what priorities it can't fund this year given its sort of budget constraints.

I think my question is more around just general oversights or what we can actually do to support oversight in perhaps a more proactive way that ensures that we are moving forward with the various milestones that are required to set up a program and establish the program and ensure that the funding that we appropriate in prior budget years actually gets allocated and that the initiatives get set up.

Because then we're faced with, on paper, seeming to make a very reasonable cut of a critical program around eliminating psychiatric loan repayment program or cutting what is it? 200. What's the number here? Here, $115 million from community health workers. And the funding related to that just on and on, where the things that are left on the table to cut are essentially things that were just not implemented, where we weren't able to be able to move forward with spending, spending the money that we committed to spend.

And what I'm asking from you all, what can we do as a Legislature to perhaps provide greater oversight in these hearings, which is what we're here for, to ensure that when we set up legislation or move forward with initiatives, those programs actually get implemented?

Matt Aguiler, Department of Finance. So I appreciate the question, and, yeah, I can assure you that there is no intentional delay, you know, on the part of the Administration in terms of rolling these programs out. The workforce package, you know, in total was a huge package, and those funds were appropriated funds over a multi-year period. So those dollars, as those dollars are moving through over the various multi-year allocation, you know, there was a tremendous amount of work that went into getting those programs funded.

And, you know, this happens to be one that the money, you know, the effort was not completed and the money had not gone out the door. We also were in support of the program.

It just happened to be that, you know, one of the things that we were looking at when we were trying to figure out how we're going to solve the budget problem was to look at, you know, things that were in flight, but the money had not yet gone out and this item just fell in that pot of funding.

So I guess what Assemblymember Bonta is alluding to, I am alluding to, and, you know, if you are part of any other hearings. I guess there has just been an expectation that when we, you know, pass a Bill or we pass a budget and we state that this is a priority, we want this done, that it will actually get done. And if it's not, and we ask why, there is a reason why. And that's why I've been asking why was this not implemented?

Was it a problem with not having enough people to do it? Was it something more logical, logistical? I don't know, but I'm not getting those answers. It's just that it wasn't done. And now we are in a different kind of budget outlook. And so we need to look and see where we can kind of cut some things or trim some things that would cause the least amount of harm. And since this was never implemented, then it's kind of an easy first step.

But, you know, when we talk about oversight or being able to work together, to have some kind of communication and say, hey, you guys passed this a year ago, two years ago, three years ago. This is a legislative priority. We haven't been able to do this because X, Y and Z, and we're looking at this program now because of where we are in the budget.

But if we were in a different place, we probably would have never known that this still has not been implemented, and that is a problem for us. You wanted to say something?

Yeah, if I may, I just want to add. Again, Libby Abbott, the Office of Health Workforce Development at HCAI. I should say I'm new in this role. So I've been here six months and so I just want to offer what I've observed, which is building on what you just described. While we were working on the program, we may not have gotten to execution, and that's because our workload and our budget 10x over a period of a few years and our staffing 2x.

So this is not to make excuses, but you did sort of suggest, is this because we didn't have enough people? We're still catching up on that workload. So I described some of the work we did, for example, with CYBHI, which is a significant amount of work. We're creating an entirely new profession in the state, and that required an immense amount of research and a lot of staff effort went to that. Same thing for the Reproductive Health Initiative. Some of that work is actually not workforce work.

So it takes a lot of energy for us to figure out how to design and roll that out. And we know that that's also a Legislative priority. So I just want to offer that on behalf of my team, because I'd be remiss if I didn't. I think they're doing the best that they can, but we had a significant increase in resources and programs and we are doing our best to keep up.

So are you stating that you all prioritize the things and based on your workforce, you didn't get to it? Is that essentially what you're saying?

We had. We were juggling a number of priorities, and so the design of this program was in the works. We just hadn't gotten into execution yet.

And again, just a broader conversation to be had, and we could probably be having this conversation with any Department sitting here. So sorry that it's kind of coming forward. When we move forward with legislation, we go through an appropriations process. It gets tagged with a particular fiscal amount associated with that initiative. My understanding is that the requisite staff required to be able to move forward with that initiative is essentially accounted for, in the fiscal tag, which is why fiscal jumps significantly on projects.

My assumption is that means that there is our additional bodies and staff that are hired or reallocated to be able to move forward with a piece of legislation or an initiative.

So I'm having a hard time kind of jiving the statement that you just made, which essentially said the priorities that we were required to move forward with went up 10x, but the staffing did not go 2x. Because my understanding is, commensurately, because my understanding is that we actually are paying for and allocating funds when they're passed through legislation to be able to do that. So I'm confused.

Yeah. And I might offer it to the finance.

Yeah. I would just say, I think with legislation it is somewhat of a mixed bag. But you're correct that, you know, oftentimes there is a State Administration piece that goes along with whatever the policy is that's being considered through legislation.

Okay, so we'll settle on the mixed bag and maybe we'll take it up with our budget sub-seven as a broader conversation. Thank you.

Just to sit on that point, in terms of, you know, what tools, oversight tools are available to the Legislature. Of course, you know, hearings are a key oversight tool. There are other oversight tools. For example, sometimes the Legislature adopts reporting language that helps facilitate oversight because it requires the Administration to formally report on measures that the Legislature develops. There are other oversight tools, too. So there are various oversight tools available to the Legislature as it sort of weighs how to best oversee.

There are a lot of initiatives here, so there's a lot of options here for the Legislature to- consider.

Thank you. Just one more question. So there are proposed delays in healthcare workforce. How do you think that these delays are going to impact worker training?

So there are three major buckets of delays. $70 million for the nursing initiative, 70.1 for social work initiative, and 189.4 million from the Mental Health Services Fund. We have estimated what we think, how we would have used those funds, and the impacts they would have had.

So for the nursing initiative, we are in the process of programming our existing 70 million, and so applied the estimates of that programming to the 70 million we would have gotten next year, and we think we would have reached about 3570 nurses through scholarships, education, capacity expansion, and interventions designed to address burnout and clinical training. So deferring that money a year will defer the impacts of those programs a year. So for the Social Work Initiative, the $70.1 million.

Those funds were primarily going to augment existing programs and enhance upcoming funding cycles for the following programs. Social work education capacity expansion, scholarships for undergraduate students pursuing social work, funding to support masters of social work students that are completing their pre and post-degree clinical hours, funding to enhance the capacity of clinics facilities, and other service settings to supervise social work students.

With that funding, we will not be able to implement or expand some of those cycles and we estimate that we would have reached 1,634 social work students through those scholarships, fellowships, supervision, and capacity expansion. And then finally, with the delay in Mental Health Services Fund, some of that will impact our social work initiative. We were going to allocate 51.9 million towards the social work initiative.

We were also going to stand up new programs which have not yet launched and so we don't have estimates for or number of applicants or awardees. Those would have been the addiction psychiatry and addiction medicine fellowships. University college grants to behavioral health professionals, expansion of masters of social work slots at public universities. And while we don't have precise numbers, again, we applied estimates, we think we would have reached 2,238 individuals through those programs.

So all of those impacts are delayed a year with a deferral of the funds by a year.

Wow, those are some significant numbers. Thank you so much. So, question. You know, this budget deficit that we're in is not, we're not projecting it to be for this year alone. So how do we know that we're saying that this is going to be delayed for one year. How do we know it's not going to end up being a delay for two or three?

And so these numbers that we're hearing about will then be to three times fold in terms of the impact on our workforce within our healthcare.

I think. Matt Aguilera for Finance. You know, we typically are working on our budgets in California one year at a time. It's true that we do have data to kind of track the long-term view which is being considered. But we are back every year revisiting our competing priorities, our availability of resources and other means just through our process.

All right, well, with that, I want to thank this panel and we will now move to our third panel which will focus on Emergency Medical Services Authority. I will ask to come up Elizabeth Basnett, Craig Johnson, Christine. I'm going to butcher your last name. Lena Hong and Will Owens. And you all may begin whenever you're ready.

All right, well, good afternoon, Dr. Weber and Senator Bonta and Members of the Committee. My name is Craig Johnson and I'm the Chief over the Administration and Human Resources Division for the EMS Authority, California Emergency Medical Services Authority. And with me is Elizabeth Basnett. She's the Director. So today I would like to provide you with a brief overview of our Department, give you a brief overview of our budget, and also provide a brief overview of our three proposals.

So EMSA was formally established by the Emergency Medical Services System Prehospital Emergency Care Personnel Act SB-125 in 1980 as the state-lead agency and centralized resource to oversee emergency and disaster medical services in California. California's emergency medical system in California was created in 1981 by the Health and Safety Code Division 2.5 with the intent of creating a statewide system with EMSA, responsible for the coordination, integration of all state activities concerning emergency medical services to ensure the provision of effective and efficient emergency medical care.

EMSA is charged with providing leadership in the innovation and Administration of the emergency medical services system throughout the state, which includes setting standards for the training and scope of practice for various levels of EMS personnel. EMSA is also responsible for promoting disaster medical preparedness throughout the state and, when required, coordinating and supporting the State of California's medical response to major disasters. EMSA works closely with many local, state, and federal agencies providing private enterprises and those in disaster medical services roles to promote quality EMS services statewide.

The EMS Authority's Program functions are organized into three divisions, EMS Personnel Standards Division, EMS Systems Planning and Development Division, and Disaster Medical Services Division. For that, I'll move to the budget overview if there are no questions. The Governor's Budget for fiscal year 24-25 includes expenditure authority for 57.6 million and 109 permanent positions. Of this amount, 33.8 million, or 59%, is delegated for state operations and 23.7 million, or 41%, is delegated to local assistance.

This is a reduction of approximately 22.2 million over last year's budget, which is mainly due to a general fund reduction of 19.4 million for the California Emergency Medical Services Data Resource System, known as CDRS, and the Electronic Physician Orders for Life Sustaining Treatment, also known as EPOS Funding. The loss of 10 limited term general fund positions and various other appropriation adjustments and the Department has three budget proposals contained in the Governer's budget currently under consideration by the Legislator, which I can go through now if you like.

Proposal number one California Emergency Medical Services Information System, also known as CEMSIS maintenance and operations. EMSA is requesting 4.2 million general fund in 24-25 and 4.4 million general fund in 25-26. The requested resources will provide for the continued maintenance and operations of the California Emergency Medical Services Information system. Additional resources will continue to allow EMSA to monitor and improve California's Emergency Medical Services System to meet the patient and clinical care needs of its 39 million residents and 268 million visitors per year.

CEMSIS is a secure, centralized data system for collecting data about individual emergency medical services requests, patients treated at hospitals, and EMS provider organization. CEMSIS uses the universal standard for collecting patient care information from an emergency 911 call. For assistance, call the National Emergency Medical Services Information Systems, NEMSIS. CEMSIS data related to EMS in California is currently captured locally by EMS provider agencies, trauma centers, stroke centers, STEMI centers, and EMS for children centers. As required by title 22 of California code regulations.

CEMSIS provides the only statewide means of monitoring the overall health of EMS systems and the care that EMS agencies provide to California residents and visitors. In identifying strains and threats to the EMS systems from local and statewide events. Throughout the COVID-19 pandemic, CEMSIS has proven an essential source of critical information for evaluating patient care.

And then if there are no questions, I'll go to proposal number two. Continuation of resources for maintaining storage of emergency medical response equipment and supplies. EMSA request general fund of 3 million in 24-25, 3.1 million in 25-26, and 3.2 million in 26-27. The requested resources will be used for the continued storage and security of emergency medical resources, equipment, and supplies.

During the COVID-19 pandemic, EMSA's single warehouse which contained 25,000 square feet of storage was insufficient to house the needed equipment and supplies to support the department's COVID-19 response efforts, as well as any other future responses to meet the immediate need for space. EMSA needs three additional warehouses to support emergency operations, including the in processing and storage of nearly 16,000 ventilators and other related patient interface devices and medical supplies. To scale back warehouse storage capacity in proportion to declining emergency medical response needs after the initial COVID-19 pandemic surge.

The three additional warehouses were then consolidated in 21-22 into one single warehouse with 255,000 square feet, which includes 13,000 square feet of office space. EMSA does require approximately 255,000 square feet of warehouse space, as well as security services and janitorial service to address current warehouse operational needs and to adequately store and manage existing inventories of medical equipment, supplies, and other emergency response assets. And that's it for the second proposal. The third, so the third proposal is maintenance and repair of critical biomedical equipment.

EMSA is requesting 2 million general fund in 24-25 and ongoing to maintain critical biomedical equipment and medical supplies acquired during the COVID-19 pandemic and provide life saving, resuscitative, and medical surge services to relieve suffering for disaster victims during pandemics or other catastrophic emergencies. The 2021-22 Budget Act included 2 million general fund to maintain approximately 3,600 pieces of equipment. Funding for the maintenance contract expires at the end of 23-24.

These funds are used to contract with the Biomedical Equipment Maintenance Company via the Department of General Services, Equipment Maintenance Management Insurance Program. The COVID-19 pandemic, EMSA has approximately 3,000 pieces of biomedical equipment deployed well during the pandemic. Had approximately 3,000 pieces of equipment deployed throughout the state and country. The request outlined in this proposal will keep the said equipment ready to deploy for future large incidents, disasters or pandemics. Thank you. Questions?

Thank you so much for that presentation. Seeing that your EMT workforce was hit really hard during the pandemic and I'm not sure how well you've been able to really recover, can you kind of give us the current status of your EMT workforce and are there any initiatives in this specific area, and if not, why?

Yeah, thank you so much, Dr. Weber, for the question and for being here today. So I think with our EMT workforce, I do think the agenda did a great job of outlining is even though we've seen a 6% increase in the paramedic workforce in terms of number of licensure, and we also saw in the last five years about a 2.2% increase in the EMT workforce. We are struggling to find the data of exactly how many of those are practicing in EMS.

And so we're looking to modernize our central registry and do things that helps us capture that data. But I think, what I can speak to anecdotally and meeting with our partners statewide and providing providers statewide, is that I think with the changes that we're seeing in our society around the Behavioral Health Continuum and how EMS is evolving almost into the preventative health space. Right? When we see public health backup into the EMS system or healthcare backup into the EMS system, because those systems are overwhelmed and then people call 911, I think it becomes, you see this higher level of burnout because folks are responding to the same frequent utilizer that may be unhoused over and over.

Right? And we have all these wonderful initiatives that we're looking to implement statewide as a part of a Healthy California for All. But I think that general feeling of giving folks the tools that they really need to be successful, I think would help significantly with that burnout that we're seeing across the workforce. And again, it is anecdotally, we're trying to modernize to see if we can get more of that data in a quantifiable way.

That's really what we're hearing across our conversations. In terms of workforce initiatives. We, EMSA, do not have one, but I would be remiss not to mention that HCAI with LWDA in the 23-24 budget allocation for the workforce for a Healthy California, there is a line item initiative in there, EMS-CORE.

And that is looking to increase the geographic racial and ethnic diversity within the EMS workforce, as well as partner with communities to provide pathways for EMT certification, addressing barriers to employment through training stipends and support services. And I do think they're ready to launch 11 new training programs in 2025, the last time we met. So I know that there's a good partnership there.

Good. Thank you. And do you have an estimate on a timeframe when you will have better data to truly determine, like, who's actually working as an EMT versus who just has a license and is working, you know, in a different field?

Yeah, so the California Department of Technology, we go through the project approval life cycle, and we're in stage two now. It's a four step process to modernize our IT system. Normally, the full length of that process is three to four years. We're about two years in, so hopefully within 24 months, we would have that data, maybe less.

All right, well, thank you very much for the presentation and your time. We will now move on to the last Department on our agenda today. This is the Department of Managed Health Care. If we can have Mary Watanabe, Dan Southard, Albert Panetta again, Joseph Donaldson again, and Jason Constantouros. And you may begin when you're ready.

Thank you. Good afternoon. My name is Mary Watanabe. I'm the Director of the Department of Managed Healthcare, or DMHC. With me, I have Dan Southard, our Chief Deputy Director. The department's mission is to protect consumers' healthcare rights and ensure a stable healthcare delivery system. We license and regulate 143 plans that provide health coverage to 30 million Californians. That's about 96% of commercial and government state-regulated lives in the State. Our 24-25 budget is 163 million and 724 authorized positions.

The Department is specially funded by assessments on the health plans and receives no general fund money. We also don't have any budget change proposals currently. That's a quick overview of our budget. I'd be happy to go into kind of an overview of our different program areas, or we can go to the questions that were in the agenda. I'll defer to you on where you want to go next.

If you're ready to answer the questions in the agenda, that would be great.

So I think your first question here was, what are some of the major trends you're seeing with healthcare plans? And maybe I'll start with what keeps me up at night. I think similar to what you heard from HCAI in the Office of Healthcare Affordability, just the cost of health care. We do rate review for the individual small and large group market every year.

We typically have been seeing kind of steady single digit increases over the last few years, and for 2024, which I think many of us experienced in our own health care, we saw premiums that were double digits. The average cost of health care for our commercial market is around $600 per month in a monthly premium. So that's a significant amount of money we're seeing families spend on their healthcare at a time when we're also seeing the copayments, coinsurance, and deductibles going up.

So I think that is something that is certainly top of mind for me. And one of the big trends we saw, particularly going into 2024, and I would be remiss if I didn't mention the other one, which is just behavioral health. We're seeing, obviously, increased demand for behavioral health services, and so that will continue to be a top priority for me at the Department. So I would say in terms of healthcare trends, those are probably the big buckets.

The second question, maybe I'll let Dan, why don't you take that one?

So your second question is, what led to the rise in complaints in 2022? And do we see that continuing into 2023? And the rising complaints between 2021 and 22 were mainly related to two different complaint types, benefit coverage disputes, which could mean anyone is requesting information or service that isn't currently covered under the plan. They want to see an out-of-network provider. A DME is another large bucket of non-covered benefits. So that was one area where we saw an increase.

The other was access to care. And access to care could be, as it simply states, I can't get into seeing an appointment with any type of physician, or there may be a delay in the health plan authorizing care. So those are the main categories that fall into the access of care, access to care. We do see that continuing in 2023 and beyond. As Mary just noted, the increased demand for behavioral health services. We talked about this in this hearing.

The shortage of providers in the state had led to continued access concerns. So those are the two main buckets that we're seeing, and we continue to see those in the current year.

Before you go to the next question, just to piggyback, now, when you say access to care, is there when you really hone in on those complaints and the numbers, are they specifically referring to primary care providers, specialty services, or is it just in general?

It's across the board. It all depends. It's specific type for that consumer. But I would say the largest bucket is getting in to see a behavioral health provider at this time. And during 2022, we had an anomaly, too, because Kaiser had a strike from one of their unions that impacted behavioral health services. So we saw an increase in access to care to behavioral health services at that time, too.

Do you, and when you look at your numbers and your data, do you see trends as far as certain regions having more complaints? Do you see it more in rural areas, inner cities, or is it just across the state?

We are now building out a very substantial data analytics unit. I can't answer that question today, but I think in the near future we will be able to answer that question.

Okay, question three. This is the big one here. So we've had significant growth over the past two fiscal years. How has the DMHC utilized these resources to improve customer service for Californians? So maybe I'll highlight a couple of really recent legislation that's been signed. Obviously, there's been a lot of focus on healthcare the last few years that have really contributed to our growth.

The first and probably most significant change related to behavioral health was the passage of SB 855, which really overhauled our mental health parity law in California. Beginning January 1 of 2021, all full service health plans in all markets were required to cover all medically necessary services to treat all behavioral health conditions recognized by the most recent diagnostic and statistical Manual of Mental Health Disorders, or DSM. It also required, I think, more importantly for health plans to arrange for out of network care when appropriate.

In network options are not available within time and geographic access standards, and that's at no more than the in network cost sharing for consumers. This was really intended to make sure that enrollees were not given just a list of providers and on their own to arrange for their own care. So that was a very significant expansion that led to some growth for the Department.

The other one was SB 221, which was in fiscal year 2022-23 which applied a 10 day follow up appointment for non physician mental health care providers. So that was another one that led to growth for the Department. The other one was behavioral health investigations. So we received funding in 2021 to conduct behavioral health investigations of all of our full service health plans. We're doing about five a year to really understand the consumers experience navigating the behavioral health system.

We have very strong consumer protections here in California, but we understand there's a lot of barriers still in accessing behavioral health. So we really wanted to understand what those barriers are. And we're finding deficiencies and violations of the law, but also barriers. We also have our health equity and quality initiative. This was in fiscal year 21-22. We convened a committee to make recommendations on quality measures that we could collect, really with the goal of addressing longstanding health disparities.

The committee recommended 13 measures, which we have adopted, and we have also applied a standard of the national Medicaid 50th percentile, which we will be enforcing once we have regulations in 2027. So we had a number of positions related to that. Probably the biggest one was SB 858, which was in fiscal year 23-24. This increased our penalty amounts that we can assess when we take enforcement action against the health plans. It also gave us specific authority to require corrective action plans. And so I think we added about 40 positions to our opposite enforcement with that, and then Dan can talk about some of our workload positions.

So Mary went through our recent legislative bcps and requests for resources. I want to talk about some of our workload requests over the past couple years. The first is at our help center. Between 2014 and 2020, we saw an increase across the different program areas in our help center of 16% to 46%. And so that recent BCP requested 21 positions to help us maintain that workload and address complaints in the mandated timeframes that we have. One other workload BCP, was from our office of Plan Monitoring.

And within that office, plan monitoring, or division of plan surveys, experienced an increase in workload related to an increase in number of licensed health plans. I believe in 2015, we had 121 licensed health plans. As Mary indicated earlier, we are up to 143 licensed health plans. So to address that through our medical survey activity, we've increased the areas we're looking at in the health plans related to their compliance with the law. And so that workload, BCP, is giving us the necessary resources to do that work.

And then our final workload BCP I want to talk through is our office of financial review. And again, because of the increased number of licensed plans, it increases the workload there to conduct financial exams, not only of the health plans, but of risk bearing or medical groups. And based on findings we had had over the past couple of years, we thought it was more prudent to do more frequent examinations. So before that, BCP went through. We are conducting health plan financial exams once every five years.

We're now moving that to once every three years and once every eight years for the medical group. And we're moving that to once every five years so that BCP was to address that work club.

Well, thank you very much to our final panel. We will now move to public comment. Each individual have 1 minute.

[Testimony in Spanish]

[Testimony in Spanish]

[Testimony in Spanish]

Christine Smith with Health Access California, one of the co-chairs of the Health for all Coalition. Since 2016, California has made significant progress in removing immigration status as a barrier to our Medi-Cal enrollment. Hundreds of thousands more Californians are no longer uninsured. However, due to federal restrictions, undocumented Californians are still unjustly excluded from purchasing coverage in Covered California, our state's marketplace, even using their own money.

Right now, over half a million undocumented Californians are uninsured because they earn too much for Medi-Cal, and other than immigration status, they would qualify for Covered California plans. In addition to safeguarding the progress that we have made in Medi-Cal expansion this year, we urged the Legislature to prioritize an investment for the creation of a Covered California mirrored marketplace that would allow all Californians to enroll.

Also on item two, health access supports the work of the Office of Healthcare affordability to reduce overall costs, and we support the proposed 3% target to accomplish this goal. Thank you.

Thank you.

Thank you. Vanessa Kahino with KP Public Affairs on behalf of the California Pan Ethnic Health Network here in support of expansion of Covered California to all Californians, regardless of immigration status, whose income is too high for Medi-Cal. Thank you.

Thank you.

Hello. Whitney Francis with the Western Center on Law and Poverty and Health for All Coalition Steering member. In addition to maintaining our state's Medi-Cal expansion, we request the Legislature make investments to ensure all Californians, regardless of immigration status, can purchase healthcare coverage through Covered California. Over half a million Californians earn too much to qualify for Medi-Cal and are excluded from Covered California solely due to their immigration status.

Thank you.

Good afternoon. Matt Lege on behalf of SEIU California in support of health for all and echo those comments that already made. Also just wanted to support the support for the Striking Worker program within Covered California. It's an incredibly successful program. We'd like to continue to see that moving forward. Also support the Office of Healthcare Affordability, the 3% targets and the strong focus on workforce. And then with regard to workforce, incredible support for the Medi-Cal workforce pool, investment from the MCO tax within HCAI. I think that's a really important program, particularly given some of the delays and cuts on the workforce side. Thank you very much.

Thank you.

Good afternoon. My comments are in relation to item number three. My name is John Poland. I'm representing the Emergency Medical Services Administrators Association of California. So we represent all 34 local EMS agencies in all 58 counties in California. I'm also the regional Executive Director of the Sacramento Valley EMS Agency, which represents 10 counties in Northern California. And we're just here in support of the EMS authority, their budget priorities, and the work that they do as a partner for our organizations. Thank you.

Thank you.

Good afternoon. I'm also here to talk about item number three. My name is Dave Magnino and I'm a EMS administrator for Sacramento County EMS agency and have been for over 10 years. I'm also a licensed paramedic and former CHP officer that I first started working with the state EMS authority in 1983 when I first became an EMT. And since then I've had an intimate working relationship with all staff members at EMSA, and they do a great job. And so I'm totally in support and Sacramento County is in support of their budget proposals and request that you consider that. Thank you.

Thank you.

Hello, Chair. Janice O'Malley with AFSCME California. I just wanted to echo our support for Health for All. Also wanted to express our support for $20 million from the Healthcare Affordability Reserve Fund for AB 2530, Healthcare for Striking Workers, as well as clarifying that funds may be continuously appropriated from that same source, and also wanted to again express our support for the Office of Healthcare Affordability at the 3% cost target. Thank you.

Thank you.

Madam Chair Member, Sara Flocks, California Labor Federation. We are here mainly on Health Care for Striking Workers and wanted to explain a little bit about the ask that we have. As you can see from the answers from Covered California, strikes are very hard to predict. We narrowly avoided a Teamster strike, which would have been 40,000 workers who are at risk of losing their health coverage. We avoided that.

So right now, the $2 million that was allocated is sufficient to cover what could be a large number of workers who would be left without coverage. And so what is really most important in our ask and the reason we did 20 million, was to show that that's what could be the cost of strikes. Hopefully not.

What is most important is a continuous appropriation from the Healthcare Affordability Reserve Fund, so that that money we know will be able to be there if there are strikes and workers need the funding. But if it's not needed, it stays in the Fund. And hopefully, with AB 2530, we actually will avoid strikes. That is our goal. We don't want to use this money. We want to avoid strikes. And we think by taking this weapon away from employers, that could be possible. So we would urge the continuous appropriation, and we also support the Office of Healthcare Affordability and the 3%. Thank you so much.

Thank you.

Hello. Luz Gallegos Huerto. The Inland Empire, Coachella Valley here supporting it. One Health for All expansion, especially for undocumented immigrants, that we through our grassroot work, we continue to see our state's most vulnerable workforce, Farmworkers that are not qualifying, that expose their life to feed us all.

Through pandemics, exposure, climate change, and more and more, we are seeing that many of our members, especially here, the ones that are here representing thousands of our state's farmworkers, that are not qualifying for Medi-Cal because of the way the threat of their household income is considered. Please support this. Thank you so much.

Thank you.

Hi, Madam Chair, my name is Chloe Stack. I'm here on behalf of the California Immigrant Policy Center. We're proud to have worked on the Health for All campaign for the last decade, and we want to thank the Legislature for their leadership in successfully achieving Medi-Cal for all. I just want to uplift all the comments of our partners and coalition members here. When everyone is able to access the care they need, we move closer to our vision of an effective and equitable healthcare system by covering as many lives as possible and promoting the well being of all Californians. Thank you.

Thank you.

Good afternoon. Johan Cardenas with the California Pan Ethnic Health Network and the Havanar State Coalition, also a proud member of the Health for All Coalition. We respectfully request the Legislature to prioritize and include investments in the 2024-2025 state budget that will ensure all Californians, regardless of immigration status, can purchase healthcare coverage through the Covered California marketplace.

We also believe that by creating a mirror marketplace that's affordable and accessible for undocumented Californians could also be a key step in advancing California's progress in moving towards a universal coverage and also improving equity in access to health coverage for all. By ensuring that everyone is able to access the care they need, we build a stronger and more healthier California. Thank you.

Thank you. And seeing no more public comment, I want to thank all of the departments who came out and everyone who participated in this hearing. This hearing is adjourned.