Assembly Budget Subcommittee No. 1 on Health

Good afternoon and welcome. This is the Assembly Budget Subcommittees number 1 and 2 on Health and Human Services conducting this Joint Hearing for the first two issues for today. For issues three through nine, we will resume as sub two on human services.

Today we are discussing issues and programs related to older adults and long term care supports and services. I have said many times that when you look at the data, the issues affecting the aging population, if we don't take serious action, will be our next crisis. For California.

The homeless rates are absolutely alarming, the rates of loneliness and isolation are absolutely alarming and the entire system of care needs to be supercharged in order to meet this moment that we are facing today, especially as the growing aging population continues to march towards being the largest population in the State of California.

To that end, I really keep thinking back about some of many who I've met with. Even looking at how my parents are taking care of their parents now.

One of them with dementia and the anxiety, the stress, the phone calls I get and the growing, in many cases just desperation to be to want to make sure that those who are in their senior years are able to live out their lives with the dignity that they deserve.

And so today we want to take a deeper dive into these issues. We are doing this Joint Hearing approach because of the seriousness of this issue and to ensure that we are not even creating our own silos here as we look at these issues.

And when the announcement came out who the next chair was going to be for Budget sub one number one, I was hoping to take both of them for myself, I must admit, but.

But I got the second best thing and that is my dear friend, my dear colleague who I love dearly, who I know has a heart for doing the hard work to protect vulnerable people. So glad we were able to do this together. And so I will hand it over to Chair Addis for her opening remarks.

Well, thank you so much Assemblymember Jackson. And you're not the first person to call me second best, but my husband took umbrage with the last person who said that about me. So it is a pleasure to be here with you. In particular, I have great respect for you as a Legislator and Chairman chair of sub 2.

And just thank you to all of the people that are here today understanding how important it is that we attend to older Californians and to the forgotten middle, those folks who do not qualify for medi Cal and cannot afford out of pocket costs for long term care.

These are individuals, nearly 4 million of whom who have spent a lifetime working, saving, contributing to our communities, but who face very serious gaps in our support systems as they get older.

As I talk to folks about what's important to me in California, I often point out the fact that it's people 50 and above who are falling into homelessness at the highest rates of that population. We have a crisis among women whose spouses may have passed away and who can no longer afford living expenses.

We have a serious obligation to meet to care for our people. Over 25% of Californians, I believe, will be 60 and above by 2030. And in some communities that's even higher. In some communities it's more like 30% like mine. Along the Central coast, the there's a huge need when it comes to caring for all Californians.

And I think what we all know is that the cost of long term services and support continues to rise and this continues to increase the risk of impoverishment and homelessness and care denial for our most vulnerable residents.

And so this hearing is one of many conversations we're having, but incredibly important one as we think about our charge in terms of caring for all Californians.

Our Joint Hearing is also going to examine the community based adult services formerly known as adult day health care, or CBAs, which has become a critical tool in terms of helping older adults and individuals with disabilities remain in their communities and avoid institutionalization that can be incredibly costly and as well as for some, just not the right fit.

However, the providers that are delivering these vital services continue to face significant sustainability challenges. And just a few weeks ago in the sub one hearing we heard similar concerns from providers of other long term care providers under the Department of Healthcare Services, including Congregate Living Health facilities and the program of all inclusive care for the elderly.

Sustainability is even more uncertain and I've said this at every single sub one hearing as we face potential cuts to the Medicaid program at the federal level that would affect our Medi Cal program here in California. And we know that those cuts aren't imaginary.

We just faced $11 billion in cuts to the public health system that for fortunately our Attorney General brought a stay and we got those monies back. But that was an $11 billion cut to California. We have seen Title 10 cuts to family planning. There was a $390,000 effect on the Central coast to one of my organizations.

We know the Federal Government is taking action and we need to be astute and strategic and thoughtful about how we move through this moment. I'll also say that today's Joint Hearing is an important step in discussing options that are available to ensure long term services and supports remain accessible, affordable and viable now and into the future.

And we have to be ready, not only with a sustainable strategy, but a clear and coordinated approach. I often think about how we are going to fulfill California's promise to our residents, to every single one of our residents, regardless of their background and also regardless of their age.

And oftentimes you hear from older communities that they feel forgotten. With this hearing, I think we want to let all of the older Californians know that you're absolutely not forgotten in that we are here to uncover what we need to do and to be thoughtful in our approach.

And so I want to thank the Chair again, thank Assembly Member Jackson again for getting our subcommittees together. We work very collaboratively across many fronts and look forward to working with you as we tackle these issues.

Thank you very much. Well done. I don't know about you, Assemblymember Addis, but when I meet with stakeholders on these issues and we talk about the state budget, one of the last things I'm always told is, is that this is what we need.

But we're so glad we're not in your shoes to have to make the tough decisions. But I'm actually glad that we're chairs during this time because if we're not, who will be?

If those of you who are here in this room and who are watching aren't the ones who are responsible for the advocating and the analyzing and the recommending, who better than us to be in this moment to try to do the most good with what we have?

And so it's these times like this where we recognize that sometimes the times choose us. And yes, I was one that said when we both got sworn in, oh man, look how much money they're getting and giving away. I said, wow, I can't wait. I started making my list before I was sworn in.

And then the budget tanked and then we were left with survival mode instead of what people are starting to call abundance these days. Right? But I know we can do this and I know that at this time there's no such thing as over communicating, over sharing, because we've got to get this right.

And I am so excited to see what we're able to do together. So let's get started with our first panels. Each panelist will have five minutes to present and you will hear the timer after that point and where you are supposed to conclude. I repeat, you're supposed to conclude.

Members of the public will have two minutes each to make their remarks at the end of all of our panels as well.

So for our first issue, we are going to be bringing up such an important issue that many of our families are encountering, especially when they find out that they are a part of the forgotten middle and looking forward to talking about the long term care supports and services that they need. At this time, I will allow Department of Healthcare Services to begin when you're ready. Great.

Good afternoon Committee chairs and Members. My name is Susan Phillip. I'm Deputy Director for Healthcare Delivery Systems at the Department of Healthcare Services.

I will first provide a brief overview of what is covered under Medicare and Medi Cal and outline recent efforts in Medicare and Medi Cal to help address the challenges facing aging Californians to connect them to long term services and supports.

I will also touch on the pressures facing public programs and then hand off to my colleague at the Department of Aging to briefly set some context. Medicare, of course, is a federal health insurance program primarily designed for individuals age 65 and older, as well as certain younger individuals with disabilities.

While Medicare provides essential coverage for various health care services, it does have significant limitations when it comes to long term care. Specifically, Medicare does not cover most long term care services such as custodial care provided in nursing homes.

Medicine and this limitation can leave many seniors and their families facing substantial out of pocket expenses when seeking long term care options. Medicare does offer limited coverage for some short term skilled nursing care, but really under only specific conditions.

For instance, if a patient has been hospitalized for at least three days and requires skilled nursing care or rehabilitation services afterwards, Medicare may cover these services for up to 100 days in a skilled nursing facility. Given these limitations, many patients may need long term care beyond what Medicare can provide.

Furthermore, Medicare does not cover home and community based services that many individuals prefer as alternatives to institutional care. About 6.5 million older adults in California are covered by Medicare. Medi Cal covers long term services and supports for low income individuals of all ages. However, Medi Cal does not cover middle income older adults.

Most Californians cannot afford to purchase private long term care insurance. Paying out of pocket for long term services and supports is cost prohibitive for many and creates a significant financial and social burden for families. Consequently, many Californians may forego the care they need or alternative alternatively incur high out of pocket costs that can lead to impoverishment.

There has been federal efforts to address this issue. Back in 2011, a national solution to the challenges of long term services and supports of the affordability of that was envisioned under the Affordable Care Act.

Under the Community Living Assistance Services and Supports act, also known as the CLAS act, the concept there was to establish a voluntary and public long term care insurance option for working adults.

However, later that year In October of 2011, the Obama Administration deemed it was actually actuarially unsound and announced that it would be dropped and that was really due to adverse selection concerns, high premiums and the potential for unsustainable financial burden. Since 2011, the nation's aging population has increased exponentially, making this issue even more of a concern today.

While the federal CLAS act was dropped, some states, including the State of Washington, explored the feasibility of standing up a state level public long term services benefits. Since that time, the Washington State has implemented a public LTSS benefit financed by state payroll tax.

In recent years, California has examined the feasibility of long term services financing options under the 2019 Budget Act. That act authorized funding for Department of Healthcare Services to contract with a qualified entity to conduct a feasibility study and an actuarial analysis of long term services and supports looking at the financing and different service options.

DHTS worked with Milliman, a national actuarial firm to prepare this study and the final report was produced back in September of 2020 and is available on our website. That report provides a set of policy options and fiscal estimates and actuarial analysis of the various policy options.

I will also note that California authorized in 2019 the long term Care Insurance Task Force under under the California Department of Insurance. The task force was in effect until last year and that task force commissioned a feasibility report on Long Term Care Insurance Program which was completed back in 2022.

It also commissioned an actuarial analysis which was completed in 2023 and these were prepared by Oliver Wyman, an actuarial firm that's also available on CDI's website. The report provides an overview of potential trade offs on program design options and I will just acknowledge that the demographic trends may place additional pressures on public programs, including Medi Cal.

As of October 2021, about 2.26 million seniors and persons with disabilities were enrolled in Medi Cal. Looking back in October 2024, we have 2.48 million Members that are enrolled that seniors and persons with disabilities enrolled in Medi Cal. So a modest but steady upward trend.

On a final note, I will note that as Of January of 2024, DHCS eliminated the asset test for Medi Cal Eligibility. This is an important step in affordability for older adults and persons with disabilities who may have income levels that would qualify them for Medi Cal but may have had assets that would have deemed them not qualified.

So older adults and people with disabilities must still have accountable income below 138% of the federal poverty level to qualify for Medi Cal. But again, the asset test limit has been eliminated. So that concludes my remarks and I will turn it over to Sarah from cda.

Thank you so much. Chair Addis Chair Jackson My name is Sarah Steenhausen. I am Deputy Director of Policy, Research and Equity at the California Department of Aging.

I'm going to be speaking speaking to you about the Department of Aging's Long Term Services and Supports financing initiative and efforts to understand California's what we're calling the overlooked middle population as opposed to the missing middle. And I'll talk to you a bit about how we're defining that as well.

When we talk about long term services and supports, I just want to emphasize that we're talking about both home and community based services that are provided in the home and the community, as well as those services that are provided in institutional settings.

So again, as my colleague Susan referenced, these are the kind of non medical services that people need support with, such as bathing, eating, dressing, transferring mobility, as well as medication management, meal preparation, and others.

Addressing challenges in how to finance long term services and supports, particularly for those who are not eligible for Medi Cal, is a key component of California's Master Plan for Aging.

There is no one size fits all approach to addressing this long term care financing crisis and it is first important to understand and define this population, their current needs, their projected needs, what that will look like in the future, and what the policy options are to address this issue.

So In March of 2024, the California Department of Aging, in partnership with with the Department of Healthcare Services and several project partners, launched the Long Term Services and Supports Financing Initiative.

This initiative was funded through the 2022-23 budget and it includes a population analysis as well as policy and program analysis to address this long term services and supports financing crisis. Specifically, the analysis will continue consider the impact of LTSS need on income adequ as well as caregiver capacity and availability, and implications for availability and access to services.

The analysis also will include this updated definition of who falls in this category of the overlooked middle, including a population analysis and future projections of the overlooked middle. Third, how the federal Medicare program could play a role in financing a home and community based services benefit under specified conditions that actually we believe could save Medicare dollars.

Fourth, the initiative includes two surveys of older Californians focusing on their LTSS needs, affordability, and preferences for potential policy options to address their current and projected needs. And then finally, we are hosting a series of listening sessions of older adults, people with disabilities, and their caregivers from across the state.

All of this is being done in partnership with several project partners. So I'm now going to talk to you for a second about how we're defining the overlooked middle. So as we've noted, there are many different terminologies and definitions for this category of middle income older adults who have trouble affording long term services and supports.

So through the Long Term Services and Supports Financing Initiative and with the support of the Urban Institute and UMass Boston, we have adopted the term overlooked middle to set a benchmark for what constitutes an income level that is necessary to afford the cost of $50,000 worth of long term services and supports per year without impoverishing oneself.

This working definition includes households that typically do not qualify for medi Cal coverage before or after the onset of LTSS needs. Households that can typically afford basic living needs in the community but would have to reduce expenditures on their basic living needs in order meet their long term services and supports needs.

So using this definition, we have defined the overlooked middle as adults age 60 and older with annual incomes between approximately 139% to 500% of the federal poverty level, which translates to single households falling between roughly $21,600 and $78,000 of annual income. Or for couples it would be $29,000 through 106,000 DOL approximately for a couple.

These are individuals who don't qualify for full medi Cal coverage and most would be unable to afford $50,000 worth of LTSs expense without compromising their basic living needs. $50,000 translates to roughly four hours of home care per day per individual.

So we recognize that for that range between 139% to 500% federal poverty level, there's not one approach that can meet their needs, and we certainly recognize that the General Fund can't solve this solution.

There are many different approaches that we have to consider across the continuum, and what I want to close with is that it is estimated that in 2023 approximately 3.86 million Californians age 60 and over fell in this overlooked middle cohort.

We are continuing to work with UMass Boston and our project partners through the Urban Institute to Analy current and potential LTSS needs and identify factors driving that potential need for LTSS, as well as future population projections.

We are rolling out products from this initiative over the next year, and the final report will be delivered to the Legislature in June of 2026. Thank you for the opportunity to present this information. I'm happy to answer any questions and I will turn it to my colleague Claire Ramsey at Department of Social Services.

Thanks, Sarah. Good afternoon. Thank you, Chairs Jackson and Addis for having me here today to speak on this panel. I'm really going to focus on Question four in your agenda, since my colleagues at DHCS and CDA have really teed up a number of pieces related to the overlooked middle and those challenges.

We do want to acknowledge that IHSS is a Medi Cal funded benefit, obviously providing a significant number of individuals in California with LTSS services, but we are speaking on it later in another panel and it is a Medi Cal benefit.

But we do see that there will be pressure on the program as older adults increase in the state. And as Chair Addis mentioned, we do expect to see in just five years that nearly 25% of Californians will be age 60 and over. While we have seen poverty decrease for the General population since 2012, it has increased slightly for older adults.

Additionally, we do see that half almost of single adults who are experiencing homelessness are now 50 and older, and more than 40% of older homeless adults became homeless for the first time after they turned 50, which I know our colleague Dr. Kushel will speak about more eloquently.

CDSS has a role in administering a number of programs across a wide array of services and supports, and the agenda did a very good job laying out a number of the programs that we administer.

So I really wanted to focus on a couple of major initiatives that we have that are aimed at increasing capacity in our licensed care settings. First, I want to focus on the Community Care Expansion, or cce.

Community Care Expansion is a program that is focused on expanding and preserving licensed care and expanding to also permanent supportive housing and other forms of care for older adults and individuals with disability either experiencing or at risk of homelessness who are applicants or recipients of Social Security income, SSI or state supplementary payment, SSP and the Cash Assistance Program for immigrants.

However, we think these programs will also have a follow on effect of preserving facilities that are serving a wider spectrum of older adults since not all facilities are 100% SSI funded. As I said, there are two components to CCE.

The first is the Capital Expansion Program which funds expansion of housing and care with supportive services through acquisition, construction and rehabilitation. And the second is the CCE Preservation Program which aims to immediately preserve and prevent the closure of existing licensed residential adult and senior care facilities serving the CCE population.

First, for CCE capital expansion, we have now awarded all $570 million in our local communities and we expect that to produce more than 3,100 beds or units. And we say beds because that's the reference to them being in licensed communities. And then units obviously are permanent supportive housing units to serve the older adult population for CCE preservation.

We have awarded $247 million to 34 different counties and we are already seeing counties get into contract with facilities and start to preserve placements in those facilities.

So as of March 2025, at least 16 counties have already contracted with 103 facilities to preserve 2,251 beds within licensed adult and senior care residential programs that were at risk of closure and are serving the CCE population.

We do want to note that over the life of this program we do anticipate creating or preserving around 7,000 beds and units in total. The other program I wanted to highlight was created through an Assembly Bill 2119 by Assemblymember Flora. This is the Medical Foster Homes for Veterans licensing category which is new to the state.

So the Department is currently working on the development of this new facility type specifically for veterans. In collaboration with the Federal Veterans Administration, the Department is creating this Medical Foster Homes Veterans model which exists in other parts of the country.

This is an innovative model that aims to provide housing for veterans in a family setting with the goal of preventing homelessness among California's veteran population. These medical foster homes will be small home like environments designed to assist the veteran with daily activities of living while coordinating any necessary medical care through the local va.

We do anticipate this licensure category to be online later this year, likely in fall.

And then finally I did just want to touch briefly, even though it was laid out to some extent in the agenda around our capacity within our Community Care Licensing division, we are happy to say that we are seeing generally increased capacity in both our facilities and in the number of beds available, both generally across our adult and senior care programs and specifically in our facilities that serve recipients receiving ssissp.

And the agenda lays out those numbers over the last few years. With that, I will pause and turn it over to my colleague, Trinh Fan.

Good afternoon Chair Jackson Chair Addis My name is Trinh Phan, Director of State Income Security at Justice in Aging. Justice in Aging is a national legal advocacy organization.

We work on many issues, including long term care to advance the rights of low income older adults Across California and throughout the nation, older adults and their families are feeling the unbearable burden of unaffordable long term care. Most older adults and people with disabilities need long term care services and supports as they age.

Californians overwhelmingly want to receive support to live and age in their own homes and communities, but the ability to do so requires navigating a complicated patchwork of programs. As you heard earlier, and contrary to public opinion, Medicare does not cover most long term care.

It's Medicaid or Medi Cal here in California that is the primary payer of LTSS. There are about 2.3 million older adults and people with disabilities currently receiving LTSS through Medi Cal. But There are over 4.4 million older adults and people with disabilities who are outside of Medi Cal eligibility and unable to afford their LTSS needs.

The majority of older adults and those with disabilities who need LTSS and can't access it through Medi Cal live on incomes of less than $60,000 a year. 40% of surveyed California older adults have unmet LTSS needs, and nearly 2/3 of California adults who need LTSS experience financial worries.

This is clearly a problem in need of an urgent solution. As you heard earlier, the demographics of our state are changing. By 2033, almost 90% of Californians age 75 or older will have incomes between 25,000 and 100,000 too low to afford privately paying for LTSs but too high for Medi Cal.

This is a huge income range, and California has still not taken the steps to address the affordability challenges for those with incomes near the bottom of that range by implementing share of cost reform.

The Legislature has rightly been talking a lot about affordability here in California, and this issue of unaffordable LTSS should be one of the top issues that the Legislature is committed to addressing. Lack of affordable LTSS perpetuates intergenerational poverty and disproportionately impacts communities of color, especially women who are family caregivers.

Failure to adequately invest in home and community based services will lead to more older adults and people with disabilities entering long term institutionalization, which costs the state four times as much.

While the state considers long term options to increase access to LTSS through things like the HCBS roadmap and LTSS Financing study, there are steps that must be taken in the short term and that do not require additional studies. I'll end with three things the state should be prioritizing.

First, the most impactful thing the state could do to increase access to LTSS is reforming the Medi Cal share of Cost program, which would make accessing Medi Cal services easier for those who are just out of income eligibility.

Now, the current Medi Cal share of cost policy requires older adults and people with disabilities who are just $1 over Medi Cal eligibility to have to spend nearly all their income each month on health care expenses until they're left with just $600 to live on for the month.

This reform passed in the budget with unanimous bipartisan support in 2022. However, implementation has been indefinitely delayed, indefinitely delayed due to lack of funding. Reforming this program would improve LTSS access for over 100,000 older adults and people with disabilities, and we thank Assemblymember Chiavo for championing this proposal.

Second, prioritize housing stability for low income MEDI Cal beneficiaries receiving HCBs by standardizing room and board rates for those residing in assisted living. And third, preserve coverage for Medi Cal's hcbs even in times of budgetary constraints that the state is facing.

Research shows that cutting hcbs will lead to increased hospitalizations and institutionalization and higher costs for the state. It's imperative that we take the steps to improve access to our LTSS system.

There are literally millions of people and families that struggle every day to afford and coordinate their care, and the longer we wait, the harder it will be to help. Thank you, and I'll pass it over to Dr. Kushel.

Thank you. Good afternoon, Chairs Jackson and Addis and other Committee Members. I'm Margot Kushel. I'm a Professor of medicine at UCSF, where I direct the Benioff Homeless and Housing Initiative. And I came here today to talk about an issue related, although not exactly the same, which is the issue of older adults homelessness.

On a given night, over 180,000 Californians experience homelessness, two thirds of those in unsheltered settings. And despite California's efforts to prevent and end this crisis, it continues to worsen. Those 50 and older represent the most rapidly growing group between 2017 and 2022 in California, the proportion of adults 50 and older accessing homelessness services nearly doubled.

My research has found that in the early 1990s, 11% of single homeless adults were 50 and older. 2003, 32% were. And most recently, in our statewide study of people experiencing homelessness, 48% of single homeless adults were 50 and older. Among those 50 and older, 41% had never been homeless, not even for a night before they turned 50.

As a physician, I can tell you that homelessness is absolutely catastrophic to health. When people are homeless, they must devote all of their efforts to basic survival. They're confronted with punishing environmental conditions, fear and exhaustion. Their ability to access medical care and adhere to complex regimens becomes almost impossible. Chronic conditions worsen. Infections and injuries are common.

As adults age, it is typical to have a higher burden of chronic disease and a higher degree of impairment, like difficulty walking. But disability is always contextual. Disability is really the interaction between a person's impairments and their environmental conditions. So homelessness among older adults not only worsens health, but increases disablement.

In homeless adults 50 and older, 43% reported at least one limitation in activities of daily living, and 23% with three or more. And almost all of them had unmet need for assistance. California's housing affordability crisis acutely impacts older adults. We have only 24 units of housing, affordable and available for every 100 extremely low income households.

We are 1 million units short of where we need to be. And it's important to note that it is renter households, led by renters 50 and older, who are most likely to be severely rent burdened. From our statewide study, we found that those just before becoming homeless had very low incomes, $920 a month.

So housing was far out of reach with them. But the most common reason for housing loss for older adults was an interruption in income. Those who first became homeless after the age of 50 were able to name a discrete event that precipitated their homelessness.

Either their or their partner's illnesses, their or their partner's job loss, often due to illness, their marriage breaking up, or the death of their spouse or parent, or the move into long term care of their spouse or their parent.

In several of our different studies, we have really been struck by the high number of older adults whose homelessness was precipitated after they served as a caregiver to their loved one. When that loved one either died or moved into institutional care, they were left without a source of housing and often their income.

There is important Work being done in the state on homelessness prevention, including how to recognize these discrete events with administrative data and intervene prior to homelessness. But research suggests that intervening at these times of crisis can prevent homelessness.

This is exactly what our Home Safe program is doing in our research on older homeless adults in Oakland where we follow people once who are 50 and older when we enroll them and follow them throughout. The good news is we found that 80% returned to housing. But here's the bad news.

50% of those who returned to housing entered re entered homelessness while we were following them. And the only thing that was really preventing that was having a permanent housing subsidy for those with physical frailty.

Though we need to couple community based housing supports and services that meets the needs of these aging adults, doing so has a potential not only to prevent homelessness, but to prevent unnecessary and preventable institutional care. As homelessness amongst those 50 and older rises, so does the urgency to address this crisis.

Combined, these efforts can help ensure that older Californians can age with dignity within their community. And now I'll pass it to my colleague Sarita. Thank you.

Good afternoon Chair Addis, Chair Jackson and esteemed Subcommitee Members really appreciate the opportunity to be here today to provide testimony on the forgotten middle today. My name is Sarita Mohanty and I have the privilege of serving as the President and CEO of the Scan Foundation. We are a not for profit philanthropy.

We envision a society through bold and equitable changes on how older adults age in home and community, particularly those that are from underrepresented and underserved communities. We actually have done extensive research on and outreach to older Californians and we are extremely concerned about the stagnating fixed incomes paired with rising costs in the affordability of long term care.

That's why today's hearing is so timely. I also have the opportunity to serve as a practicing physician and I've seen firsthand the tough choices older adults face. You know, I once treated a Latino man just recently.

He was in his late 60s, came into urgent care for frequent dizzy spells only because his neighbor insisted that he go to urgent care. He lived alone, had no family nearby, no real support system. The whole time.

All he said to me over and over is he had to leave, he had to go, he couldn't miss his shift and he might lose his job and he needed that income to pay for his bills, his rent and even his Medicare co pays. So his health wasn't his priority, just survival. That was his priority.

And that's what the heartbreaking reality and what we're hearing today, it's far too often I hear this, I see this amongst older adults in this forgotten middle category. So I think we can all appreciate that most older adults will want to age in their home and community.

Yet many do need that long term care, home care, adult day health care and assisted living at some point in their lives to help with things like bathing and dressing.

And we heard about this through my colleagues that Medi Cal we know covers long term care, but many of our older adults do not qualify for medi Cal and Medicare doesn't cover those services. Family caregivers have, you know, we heard also often step in to provide care for loved ones. But this has its own set of challenges.

Sometimes people cannot afford to leave work to care for a loved one. In other instances, older adults may not have family living nearby or to provide care like the patient I mentioned earlier. So this leaves a significant gap of care for a large segment older adults and we do, as mentioned, call this the forgotten middle.

These are people who make too much to be eligible for Medi Cal but not enough to afford the long term care they need. Their incomes range in our analysis between 25,000 to 101,000 a year.

We did some research, we actually commissioned some research with the University of Chicago in Newark and showed that 1.6 million Californians over age 75 will fall into this forgotten middle category by 2033. That's a 60% increase from current times.

Nearly half will be people of color and most will experience multiple chronic conditions and functional limitations at some point. Half won't have a family Member nearby to support them and most won't have the income or housing equity to pay for the assisted living or in home support.

Then I would be remiss if I didn't mention there's a subset of the forgotten middle. It's called the near duals. They are even in a more precarious position. One in eight older Californians just miss the eligibility or cutoff for Medi Cal yet have the same level of health and service needs as Medi Cal beneficiaries.

But without access to care, the idea that they can spend down to qualify for Medi Cal is unrealistic. When they still need to pay for their housing for their food and other essentials. One thing I think it's really important we said is that it's really critical to listen to the older adults.

We've been doing this around the country through our project which we call the People say. I'd like to mention and quote Melanie, an older adult we heard from who summed it up best, quote, healthcare is up there like number one is what she says.

But then you need food, then you need rent, then you need personal items, your toiletries, but then there's nothing left for anything else. You're living on a survival mode from day to day and that in itself is stressful and frustrating.

So the path forward, I think is that California has made significant progress through the Master Plan for Aging. We've expanded medical eligibility, built a stronger State of infrastructure to support aging. We can't afford to lose ground on these advancements. In fact, any cuts to Medi Cal would only deepen the affordability crisis we've discussed today.

We need to protect the progress we've made and continue to work toward policy solutions that meet the needs of of all Californians. And so we know that the long term care crisis is not going to go away, as was mentioned.

And with the increased growth, with the unaffordability and tackling this crisis, we're going to have to be bold. We're going to have to take bold action and continued commitment and we're going to have to listen to the voices of those most impacted, those older adults, to inform programs and to inform policy.

So in closing, I'd like to thank you for prioritizing this really critical issue. I think let's ensure that growing older in California means doing so with dignity, care and choice for everyone. And the SCAN foundation is ready to be a resource as you explore solutions for long term care. So thank you very much for your time. Happy to answer any questions.

Thank you very much. Department of Finance

Jennifer Ramirez with the Department of Finance. Nothing further to add.

LAO?

You get two of us today. Karina Hendren, LAO Today we wanted to share that the LAO published an analysis of recent increases in Medi Cal's senior caseload. That analysis is available on our website.

Our review found that the recent growth in the senior caseload is due largely to several policy changes enacted by the Legislature over the past few years that have expanded access to Medi Cal for the senior population.

These policy changes include the elimination of a medi Cal share of cost for seniors up to 138% of the federal poverty level, as well as the elimination of the asset test that was previously used to determine Medi Cal Eligibility. And my colleague at DHCS alluded to this as well. So the LAO we looked at trends in the senior caseload following these recent changes in medi Cal eligibility policies.

What we found is that the combined effects of these recent policy changes have increased senior enrollment in Medi California by about 165,000 individuals and this means that a new group of seniors have now entered Medi Cal, now have medical coverage who previously did not have coverage, and as a result more seniors now have access to long term services and supports through Medi Cal.

These newly eligible seniors might have been part of the forgotten middle before these policies changes and their enrollment in Medi Cal could therefore reduce the number of individuals who fall into the forgotten middle. We do find that these results bring up a couple of issues for legislative consideration.

The first is that the Legislature might want to consider actions to ensure sufficient access to services for this growing population, including outreach efforts as seniors navigate the complex medical system, often for the first time.

And in addition, the state may want to consider actions to better facilitate access to, as has been mentioned, the less costly home and community based services to help prevent cost growth in institutional care.

And second, the duration and extent of these policy driven caseload increases will be key in eventually understanding the full fiscal and programmatic effects of the recent policy changes. Based on what we've seen before with eligibility expansions in Medi Cal, it can take time before the full effects of the changes are reflected in the caseload data.

So it could be up to another year or so before the senior caseload starts to stabilize in response to these changes. And so the Legislature may wish to work with the Administration to ensure that it understands and is tracking these changes over the coming year.

Juwan Trotter, Legislative Analysts Office no, I think my colleague did well.

Thank you. Thank you all very much. A few things and then open up for any questions or comments that colleagues may have. Obviously the I was so glad to see the asset test being eliminated because it was encouraging the liquidation of generational wealth and my my mother who's a retired nurse is a part of that missing middle.

And what other acronyms you guys and names you've called. I'm going to start I need a cheat sheet now for all the different terms you all use these days. But had to sell her home in order in order for her in order to pay for her in home supportive services. Right.

Because my mom's fixed income wouldn't be able to cover my grandmother's needs.

What are two things I think I want to know is the biggest questions that we're going to be facing this year is if we wanted to really make a dent in the progress of creating a system prepared for this influx of population and their multiple needs.

What are the two biggest investments in terms of programs should we be focused on?

Hi Sarah Steenhausen. I won't say exactly the investments in programs, but what I will say is the Master Plan for Aging lays out four prongs approach to reforming our LTSS system to make it more affordable and accessible for older adults, people with disabilities and caregivers.

First, it's helping people navigate the system and developing a no wrong door approach to service delivery.

Second is addressing access and we're looking at where home and community based services are available, where the gaps are and then we're releasing that gap analysis this year with a roadmap for how we can better meet those gaps over the next several years.

Third is workforce and how we can support both our paid and unpaid family caregivers, caregivers that provide the critical hands on support. And fourth, it's what we've been discussing today is addressing the LTSS financing crisis.

So while I'd love to say there's one or two, you know, magic bullets to it, I think that it really has to be a holistic approach as we've laid out in the master plan. But I defer to my colleagues if they have anything further to add.

And I just mind you let me I'm going to drill y'all hard on this one because now you know the questions we get right. I've read the report, I get all the different things that need to happen. But I only got a slot for one or two requests this year. What should it be?

Well, two things are one, the share of class reform to bring more people who are in that low end of the missing metal into the Medi Cal program who are now stuck in share of cost which is really, really difficult to use and be able to like any of your monthly expenses.

So bring in some of the more of the low end of that middle missing middle into Medi Cal so they can access LTSS services through Medi Cal. And that's the estimate was 100, bringing in 100,000 people that way. And there's also a proposal Bill out to for people who are in assisted living.

That's it's if you're not if you don't receive SSI and you have if you receive SSI you have rate protections built into because of your receipt of ssi. But if your income's a little higher than that, you don't have that rate protection in assisted living.

And so building in some rate protection there can help people to not be at risk of eviction from assisted living because of unsustainable rate increases because they don't have rate protection.

Anyone else?

Yeah, I wouldn't want to answer the question either. How many more CCE beds do we need?

I'll start. Claire Ramsey, Department of Social Services, one of the chief deputies. I'm sorry, I think I didn't introduce myself when I first started speaking. I apologize.

I will answer half of that but I will look to my colleague Sarah related to more the demographic needs but so community care expansion as I said is fulfilling I think a critical need within the state and we are seeing older adults who have a wide range of needs and are really on a continuum.

And obviously as sort of has been spoken to, we certainly don't want to use community care as just the only place where someone could choose to live.

But we think it is a like strong need for people who have a significant number of assisted living challenges or assist ADL's thank you activities of daily living needs and could benefit from a congregate setting.

We don't have an additional goal but I will say that we received more than 375 applications and we were able to Fund 61 of them. We as I mentioned awarded all $570 million that we had toward expansion but the request came in at about $3.8 billion of requested need.

I don't have what that would have equaled incapacity but I think it just shows that there was a pent up need out there for this program. And Sarah, I don't know if you have anything else on demographics.

Well, in terms of demographics one thing I will highlight is you know for people age 65 and older, two thirds of those individuals have their care being covered by unpaid family caregivers or friends in their home. And it is so critical.

You know again I think the theme we've heard a lot about is helping people age with dignity in the setting of their choice. And in order to do so I think we need to really think about bolstering support for those who are provide really are much of the backbone along with the paid caregiving workforce.

But these unpaid family caregivers are often unseen or unrecognized. And so I think that you know really doubling down on how we work to support them. We're going to be releasing a caregiver equity roadmap as a way to underscore our commitment to this population as well.

Colleagues, Questions Comments AssemblyMember Addis

Just have one in terms of how we address the increase in homelessness and I think you've addressed a number of things and we just in our, in our last or in one of our Budget sub hearings, we talked about medical waiver, Medi Cal waivers for rent support.

And then yesterday and health policy Committee, we heard a Bill on Medi Cal waivers for supportive housing services. And outside of putting more money and more money, I'm wondering what other creative ideas are there out there to help decrease homelessness in this population? And I think you also mentioned share of cost and how that could be helpful.

But outside of any of that, are there policy things that you haven't yet addressed that could creatively help us address the homeless issue for this age population? For anybody on the panel that has ideas on this?

One thing that might be more relatively cost neutral in this environment is this disconnect between where people at risk are seen in the system and where the resources are. So for instance, we know that most adults who become homeless, most older adults have become become homeless, have been seen in our healthcare system in the relatively immediate prior period.

But they're often not identified as at risk there or those programs don't have access to it. And I think obviously all the things you just said which are not revenue neutral, but a lot, assuming Medicaid stays intact, could be paid for by Medicaid.

But I think there's probably a lot of unmet potential to link where people are seen. We know that people, before they become homeless, particularly these older adults who are first homeless, they're often people who were sort of in the missing middle, served as caregivers, became impoverished.

They don't know this system at all and they don't know where to turn. We know that homeless prevention works if you get it to people at the right time.

And I think we could do a much better job of linking our systems of care, our aging systems, our health care systems, our social service systems and our homeless systems together to get to people right before they become homeless and intervene, which is gonna be a lot less costly than waiting until after they become homeless.

If I could just add. I agree. I was gonna emphasize one of the. Pillars you mentioned, Sarah, about the navigation piece. And I think just reiterating that there. Is a lot of waste and redundancy because so many of these individuals are. Either being, they're being reached out to.

By the healthcare system or the social system, but fragmented and poorly coordinated manner. So I think having this ability to. Have either single point of contact or. Some way like the no wrong door. Approach, I think is something we really need to invest in, which I certainly think will have positive budget implications or.

At least reduce costs because there is a lot of waste and people are. Just running through and then often end. Up showing up at the emergency Department and get hospitalized when they could have been prevented sooner. So that navigation piece is something I. Would really emphasize here.

Any other comments from folks? Thank you so much to this panel. Obviously man, we need a part two, part three part. I mean, goodness gracious. Please again continue to engage. There's no such thing as over communicating right now. Particularly need to hear from all of you during as soon as the May revise comes out.

Okay, thank you all very much. Let's bring up issue number two please. And Department of Aging. You may begin when you're ready.

Great. Thank you so much. Good afternoon Chair Addis, Chair Jackson as well as Members Mark Beckley, Chief Deputy Director for the California Department of Aging. I'll be addressing the first two questions in this section which has to do with the services and supports provided by the CPAS program as well as demand and supply for CBAS program services.

As Chair Addis had mentioned in her opening comments, the CBAS program is certainly a vital program that supports adults and older adults with their medical, cognitive, behavioral health as well as their functional needs.

Through the supports and services offered through the CBAS program, these individuals are able to remain in their homes and in their communities and avoid institutional care. The model that the CBAS programs use is really a collaborative one.

It is working collaboratively with a team of care professionals at the centers, both medical and social services, and the participants, their families and their caregivers to create what are called individual care plans.

Once these care plans are developed, services are provided to the CBAS participants and as the participants needs change over time, these care plans are then adjusted. Some of the services provided through the CBAS centers include professional nursing services, personal care services, social services, physical, occupational, speech therapies, mental health, hot meals and nutritional counseling, as well as transportation.

In terms of supply and demand for CBAS services, Currently there are 304 CBAS centers operating in 28 counties in the state with the largest concentration of centers in the LA area. Currently, the centers serve 42,000 participants.

Over the past five years, we've been very encouraged to see an increase in centers, 20% increase in new center openings, and we currently have 47 center applications in various states of review and approval. At this time, the demand for CBAS center services appears stable with most centers having capacity to enroll new participants.

As my colleague Sarah Steenhausen had noted, we are working on a GAP analysis for home and community based services. This will include an assessment evaluation of CBAS services as well. One thing in particular that we're focused on is trying to expand CBAS services in areas of the state that don't have CBAS centers.

Those areas tend to be the northern and central regions of the state, so we'd be looking at what encouragement or incentives we could give to providers to open centers in those areas.

And I'll also note that in terms of needs coming out of the pandemic, the centers did express concerns about their ability to hire and retain new staff due to staffing burnout during the COVID pandemic.

The Legislature did include a stakeholder request of $60 million in the 2022 Budget act that would allow for retention and hiring bonuses, wage differentials, as well as funding for structural modifications to Centers for Better Infection Control. CDA worked collaboratively with provider associations, including cads, to develop the grant program, which we then called Bridge to Recovery.

Under this program, CDA has awarded the full amount of the grant funding to 767 organizations. I will now turn it over to my colleague Susan Phillip, who will address the next two questions.

Good afternoon again, Chair Addis and Chair Jackson and Committee Members. My name is Susan Philip, Deputy Director for Healthcare Delivery Systems at the Department of Healthcare Services, and I'm also joined by Lindy Harrington, who's our Assistant State Medicaid Director, to help answer any questions. I will be addressing the last two questions related to the CBAS rates.

So first, to provide some Context, Senate Bill 159 from 2024 authorized targeted Medi Cal provider rate increases supported by the MCO tax. The managed care the MCO tax to be effective January 1st of 2025. This did include a rate increase authorized for CBAs.

The planned SEBAs rate increase would have increased the CBAS rate by approximately 2.7% effective January 12025 and this would have resulted in an increase for basic per diem CBAS services from $76.27 to $78.33.

However, that targeted Medi Cal payment increase authorized by SB159, which included the CBAS rate increase, became inoperative due to the California voter approval of Proposition 35 at the November 52024 statewide General election.

So the rate increase that occurred effective July 12024 was actually not related to the targeted medi Cal payment increases authorized by SB159 and later negated by the passage of Proposition 35. So I just wanted to make sure that was clear.

I know there was a lot in the spirit of over communicating wanted to walk through some of that detail zero.

You doing it well.

Thank you. So the rate change we're talking about today is actually attributed to a system mistake that DHCS made. We had mistakenly implemented a system change on June 24, 2024 that erroneously increased the Medi Cal fee schedule rates for CBAs by 10% effective July 12024.

And the system change resulted in the Seabas rates posted to the fee schedule on our Medi Cal website. It said that it increased by 10% from $76.27 to $83.90.

And because our managed care plans use the Medi Cal fee schedule rate as a benchmark in their negotiations with CBAS providers, some Medi California managed care plans began paying their contracted CBAS providers at the higher rate. So the Department received an inquiry from the California Association of Adult Day Services CADS to clarify the rate increase.

Since we had not communicated that rate increase would take place and then the Department responded saying we'd research the issue again, we clarified that it was not related to the targeted rate increase authorized by SB159. In our research, we did find that there was a system error and we communicated that back in October.

And then we also sent a communication to our Medi Cal managed care plans informing them of the erroneous rate change that was published on our website, the System Fix and will be updated on our website by mid April April 16th to be exact. And the rate the revised rate is retrospective to July 1, 2024.

So then to address the question whether any additional payments to providers would be rescinded, the short answer is it depends on the managed care plan contract and agreed upon rates. So to provide briefly a little context, CBAS is a Medi Cal covered benefit and all CBAS participants are enrolled in a managed care plan.

So as noted, our Medi Cal managed care plans are responsible for contracting with CBAS centers and as part of their negotiating or contracting process, they may negotiate rates with CBAS providers. Managed care plans again use the Medi Cal fee schedule rate as a benchmark in their negotiations, but they may pay a higher rate.

Whether providers will have to pay back the increased payment at this time really depends on the terms of the contract with the managed care plans.

DHCS is not requiring the managed care plans to recoup any portion of the increased payment, though some managed care plans may have the right to do so based on their contracts and they may choose to do so.

Managed care plans that maintain the higher rate of $83.90 can request for those higher payment levels to be reflected in their future rate payments to DHCs from DHCs. So if they pay that higher rate, it will be reflected in their future rate payments from the Department. So that concludes my comments on those two questions and I will turn it Over to Brian.

My name is Brian Rutledge. I'm the Executive Director for the California Association for Adult Day Services. Thank you to Chairs Addison Jackson for holding this important hearing. Thank you to the Subcommitee Members and thank you for your continued support for CBAS participants and their hardworking families.

CADS is the voice of the 304 CBAs centers that are currently operating and providing person centered health and human services to about 42,000 folks, including the 21% living with dementia. I'll note that for historical context here, there were 366 SEBAs centers, a way higher number than there are now 20 years ago.

So we're in an era of rebuilding. So that gives you context on the openings and closures here. That was noted in a LA Times column on Monday as well. The CBAS program is facing a financial crisis. That's why I'm here. It's accelerating in real time and it's happening statewide. Alameda, Louisiana, Orange, Riverside, Stanislaus, Ventura since June 2024.

So in recent months six SEBAs centers across six counties have closed permanently. That's 2% effectively of our state capacity. This is the wrong direction that the State of course should be headed. The cause of the continuing closures is not a mystery. Medi Cal reimbursement rates do not cover seabas costs.

So this is a long building decades old gap that's accelerated since COVID It's the CBAs rate officially has not increased in 15 years. Besides the hiccup this year that's resulting in the continued closures, we're seeing new access gaps. We're seeing higher healthcare costs. Because of that, we're seeing greater family burdens. So our solution is pretty straightforward.

We've circulated a budget request. We are asking sub one and Sub two and the broader Legislature to support our budget request for General Fund investment in the SEBAS MEDI Cal rate. Our proposal is for 74.8 million General Fund ongoing in 25-26.

The that would close in our analysis about 50% of the gap between what it costs to sustain on average the program statewide and what the actual rate is now. We would hope to come back in future years and work with the Legislature to close that gap fully.

So get 50% there in the budget year and then keep going in the future. So raising our rates is important to achieve State Policy Goals. Chair Addis mentioned the rising rates of homelessness for elderly Californians. Sebas is critical in that regard.

CBAS is critical for the success of CALAIM ECM Community Support side for the Master Plan for Aging, for ensuring that Californians can age with dignity and Independence. So there's all sorts of reasons that these committees are very familiar with in terms of why CBAS matters.

I'll also flag that in a human level, raising the rates matters because of the actual ground level impacts that these closures are having and that any potential closures in the future would still have.

So I'm in contact with families impacted by closures and they describe facing new and higher costs, worse employment possibilities and less meaningful lives and Independence for their loved ones. They describe the heartbreak of having no or worse alternatives to Sebas. Gonna read you quote My dad keeps asking when the bus will pick him up.

This is one of the caregivers and he's confused about what happened to the center. We may have to send him to a nursing home since most memory care facilities that take Medi Cal have long wait lists. Another caregiver quote Having my dad at home has limited my ability to continue to advance my career.

I fear that my career is stalled. So caregivers are telling us these are absolutely critical. I'll also note that raising our rates is particularly critical in the budget year because of the uncertainty that's been created in the current year with the the the published rate situation. I do want to respond.

I didn't anticipate the level of detail that the Administration might share, but for communicating this it was mentioned this was notified to CADS and the community in October. This is not the case. We were notified in March after the plans had been notified in February.

So the communication gap was quite large in terms of acknowledging and communicating this issue. The other is that we strongly oppose any clawbacks. We also I would question whether a plan had the right to do a clawback given that the waiver says the published rate is the published rate on the website and that rate was higher.

So for all those reasons, I would ask that Chairs Jackson and Chairs Addis Subcommitee Members please support our budget requests. Please make progress this year with us so that we can protect vulnerable Californians so that we can keep the cbas program a pillar and preserve it and grow it in the future. Thank you so much.

Isabella Alioto Department of Finance Nothing further to add. Thank you.

Juwan Trotter Legislative Analysts Office we have no concerns to raise at this time, but we're available to provide technical assistance and answer any questions as necessary.

Colleagues, any questions? Comments Assemblymember Bonta

Over the last couple years I have had an opportunity to visit several CBAS centers and just I think I met a man who was who turned 101 and clear as a, you know, clear, clear minded and he was doing ceramics and enjoying his day. And then I got a chance to talk to his family Members towards the end of the day.

And all of the things that you shared in terms of the ease of being able to have their family Member with them while they were also able to just continue to thrive and persist during their daily work was really quite powerful.

I fundamentally agree that we need to make sure that we're building out this portion of our care continuum for our elders and do have deep concerns about in these conversations I've had with CBAS providers, the very very tight margin that they run on month to month.

So it's not surprising to me that we've already had significant closures in my county and others and I'm deeply concerned about that. I'm even more concerned about it with the overlay of a systems error that may result in them having to pay back funds at this point.

I'm sure that that would accelerate several center closures if that were to happen. So I appreciate the transparency in the communication around the consequences of that system error.

But what I would urge us all to think about are we going to be able to accept as we need to make sure that as many of these centers stay open right now. So I recognize that it is within the purview of managed care facilities to be able to ask for funds to be paid back.

I think that there is clearly a dispute of whether or not that is a reasonable claim from the managed care providers if in fact what was put on a website is what is used to be able to set the rate of pay. So before the lawsuit comes that I know will come, what can we do about this.

Afternoon, I would say we have encouraged our managed care plans to consider the access needs that they have in their area when they're considering that. And again we have encouraged them that there is no requirement from the Department to recoup those funds. We've messaged that via written communication to them.

We sent them an email acknowledging that we've also shared that based on if they continue to pay those rates. Those are the that's the data that would be utilized in future rate setting versus if they are looking to to recoup those funds that would also be considered in future rate setting. But again, we do not have the ability to require plans to pay that higher rate.

So just to be specific, you do not have the statutory authority.

Can I just add thank you for acknowledging the importance of the program in terms of the closure risk. We definitely believe that any clawbacks would result in additional closures. It's worth noting that several closures happened in centers that were getting higher rates due to the accidental increase.

So if we hadn't had this apparently erroneous 10% this year, we would have seen more than the five that happened during this current year. So very, very real risks.

The other thing is I'll follow up by saying to the plans out there we did hear from the Administration, it's in win win for everyone to assume that's baked into your capitated rate.

Tell me to prevent providers from having to return the delta on this. What is that dollar amount?

I don't have that information, Chair Jackson, but we could get that for you.

I would love that and would love LAO to kind of help out with that, please. As well you have any

I had an initial analysis that we believe in the $25 million range of applying the 10% for the full fiscal year and just keeping it there. That is an analysis we don't have access to the complexity of the actuarial style capitated rate analysis. So we're an outsider looking in. But that's our stab at it.

How much did what's the total funds did we lose for when Prop 35 was enacted?

About 8 million ongoing.

$8 million ongoing. And if the rates would have stayed the same pre Prop 35 because we were scheduled to have an increase, what would that. What percentage increase would that have been?

The the Prop 35 or not Prop 35? The Budget act increases were estimated to be about 2.7%, 2.7%.

Which would have represented that extra $8 million.

That's the $8 million represented an approximately 2.7% increase.

I'll just go on record if I may to say that making the CBAS program whole by continuing the 10% at the rate that's currently on the website 8390. That seems like a great starting point for making some serious progress towards addressing the rates crisis.

I appreciate that, but I disagree and I disagree because it seems to me Even with that 10% we would still have a system on life support. Am I wrong?

I'm just throwing out there that as we've been feeling it as the new baseline for a year. So for me it's the, I mean. I know what you're saying. We'll take it right. I understand. I'm saying just as a starting point for thinking about addressing, as you said, do the most good with what we have.

And yeah, we think about it as the current baseline because the website says it currently and so we priced out our budget request using that number. So we are hoping to make of course more progress.

And tell me, I mean is this a by building out our CBEST system? I mean are we ultimately saving money in the long term by having this system in place other than what the alternatives could be?

Our analysis suggests using Genworth data for current year and budget year that it's five or six times more for a nursing home. So it's a very clear cost savings for the state and for families.

Any thoughts? LAO.

Jason Constantouros, LAO, yeah. You know, generally with any other sort of home and community based service, you know, these sorts of services are intended to, you know, provide a benefit both for the beneficiary but also for the state because it avoids, you know, potentially more expensive institutionalized care down the road. I'm not aware of any specific research right now that I can cite, but we could follow up with the Committee if that's of help.

Right. Because I mean obviously we want to talk about what's the best bang for our buck. Right. And there's been many instances, I remember last year during our budget crisis at that time and we were having arguments of whether why would we cut this program when if they go to the emergency room it's going to cost us more. Why would we call this cost, you know, cut this program?

Because the alternative is actually going to be more expensive in the long term. Right. So trying to make sure that we are clearly understanding what type of fiscal decisions we need to be making. And so that we are. I'm going rogue here. So don't respond.

I really believe that sometimes the decisions we make just to get through the year sets us up for greater failure in the years moving forward and it ends up costing us more. Right.

And I for one am tired of the annual crises and I prefer to fix things for a change, not just put a band aid over them.

And so that's why we have this panel to really make sure we understand and number one, the great benefit these programs are providing the cost savings that these programs are providing and the absolute need when we talk about what type of 21st century safety nets do we need to create that's going to meet the growing need already we are anticipating to ensure that our seniors are living with some dignity, stability and comfort.

And so I thank you all very much. I thank you for over communicating and looking forward to more discussions to follow. Thank you very much for this panel. And this concludes our Joint Hearing part of it.

I want to thank so much our two colleagues for being here as well as our Chair of Sub 1, Assemblymember Addis as well. And it is definitely something we will continue to work on as we go through this budget process. Thank you. So now just offering as a budget Subcommitee two, let's bring up issue number three please.

Issue number three. And these are issues concerning in home supportive services and collective bar and the collective bargaining report. And CDSs. You may begin when you are ready.

Thank you sir. Thank you very much. Good afternoon Dr. Jackson and Committee Members. My name is Leora Filosena. I am the Deputy Director of the Adult Programs Division at the Department of Social Services. The Essence of Time and the Timer I will just jump right in.

Yes, the IHSS program is the largest home and community based services program in the United States. We acknowledge the challenges with IHSS provider recruitment and retention and want to ensure the IHSS program has sufficient providers to serve all eligible recipients. The priority has always been to minimize barriers to working as an IHSS provider.

Consistently, the Department has focused on on getting IHSS providers paid faster by moving from manually keyed paper timesheets to electronic timesheets, which greatly reduced the time. Back in the day, providers got paid in almost over two weeks and now they're getting paid in four to five business days if they have direct deposit. More broadly, we solicited provider feedback and asked what they needed.

The feedback we received was the need for streamlining certain processes and services which led to major investments and automated self service options for IHSS providers and recipients that include electronic W2s, wage verifications, direct deposit enrollment, electronic sick leave and travel claims, and the ability to assign a provider electronically, all of which greatly reduce the time a provider waits to not only receive their pay but also have access to important documents they need to file their taxes, in some cases apply for housing and loans.

In addition to these investments in automation, there have also been additional investments such as sick leave and access to retirement savings accounts, including the ability to deduct retirement contributions directly from their IHSS wages as described in the agenda.

In fiscal year 21-22, California made a one time $295 million investment in the IHSS workforce through the IHSS Career Pathways program. Career Pathways allowed IHSS providers to take training classes in five different pathways to help enhance their skills to better serve IHSS recipients and to support the recruitment, retention and advancement of providers.

The IHSS Career Pathways classes ended on September 17th of 2024 with the program concluding on December 31st, 2024. As of January 8th, 2025, all provider claims have been paid and we consider the program a huge success with over 59,000 providers completing at least one training course. CDSS processed over 1.4 million provider claims for training time.

Additionally, CDSS also issued payments for the following incentives so we issued over $83,500 incentive claims for 15 hours completing 15 hours of training. We issued over 7,600 $500 incentive payments for one month for working one month for a recipient and over 4,900 $2,000 incentives for the six month requirement.

CDSS is currently working on a final report to the Legislature about the program which is due by September of 2025. While we're very proud of the work we have done with Career Pathways and other efforts to incentivize retention and recruitment of IHSS providers, we do not have any additional proposals in this year's budget, but we are happy to discuss any opportunities or ideas that may arise in the future.

So I'll go to question two, which is about the AB102 statewide bargaining report so Assembly Bill 102 provided us 1.5 million to work with stakeholders to analyze the possibility of transitioning collective bargaining for IHSS providers from the current county model to a statewide and or regional model.

It also mandated the Department to submit a report of the analysis to the Legislature.

The report was required to include a review of how much statewide or regional bargaining would cost for each dollar increase in wages or benefits and its potential impact on workforce recruitment and retention, potential implications on the current county state realignment structure, how any increases would interact with the statewide minimum wage increases, and what funding sources, including realignment, would be available to implement statewide or regional collective bargaining as mandated CDSS convened a workgroup with key IHSS collective bargaining participants and other state departments.

As mandated by AB102. CDSS contracted with two consultants to assist with the activities related to organizing the work group and developing the analysis.

The first consultant, High Road alliance, was contracted to assist with the facilitation of the work group meetings and the second consultant was the labor center from the University of California, Berkeley and they were contracted to conduct research on collective bargaining in General and provide their findings and data to the work group.

CDSS convened 53 hour formal work groups between April and August 24th of 2024 and we also had three level setting meetings in the months of February and March 2024. The final report I just want to make sure I know I'm at time.

I just want to make sure that I emphasize that within the workgroup and also in the drafting of the final report, CDSS served as a neutral facilitator and content expert for the work group and ensured the work group covered the statutorily mandated content and discussions and that the discussions remained within the scope of AB102.

And I did want to just take a moment because I think it's important to just kind of share some of the high level takeaways from the report. The final report is expected to be sent to the Legislature this Friday. So that's excellent news. And here's some high level takeaways.

So the first is that the work group thought the statewide bargaining was more viable than regional bargaining. The General consensus was that a regional model introduced significant additional complexities. The second takeaway was involving IHSS recipients and collective bargaining was a priority for the work group.

The third takeaway was if a statewide or regional collective bargaining moved forward, there would be a material shift in the responsibilities related to collective bargaining as they are today and are currently performed by the public authorities and the nonprofit consortium.

Specifically, those responsibilities would transition to whatever entity was responsible for collective bargaining in a statewide or regional model. The work group highlighted the need to clearly define the scope of collective bargaining in statute. The impact of regional bargaining on recruitment retention was discussed but very difficult to measure. We really weren't able to measure that.

Additionally, CDSS provided cost modeling based on point in time data and estimates. The fiscal impact to the program for each $1 as our statewide wage increase would be at least an additional 1.3 billion to 1.5 billion per year depending on the growth rate in IHSS cases with cost split between federal, state and county funds.

Additionally, the work group had discussions about liability costs, program growth and funding sources and identified legislative considerations and highlighted impacts to the county maintenance of effort and realignment that require further discussion if statewide or regional bargaining moves forward.

And then finally, I know you wanted an update on the admin funding rebase so we are current so a survey was released on January 102025 to the counties they have. The deadline for the county responses was extended to February 192025.

The Department plans to use the survey data among other information and its analysis and plans to provide that anal to the Legislature by May 14, 2025 and apologize for going over.

No problem. Thank you very much.

Tiffany Whiten with SEIU California on behalf of our over 400,000 IHSS providers represented by SEIU Local 2015. Thank you Dr. Chair Jackson for the opportunity to speak on IHSS statewide collective bargaining and the report from CDSS.

Over the next 10 years, as the aging population continues to grow, there will be an exponential rise in the demand for term care that California's workforce is not prepared for. IHSS is a life saving program for recipients and a cost saving alternative for our state.

However, the program is struggling, struggling to recruit and retain the caregivers necessary to maintain the program's integrity and struggling to get all 58 counties to have contracts, good contracts, that support caregivers. If California does not adequately invest in the workforce, older adults and those living with disabilities will not receive the proper care that they need.

Caregivers will continue to live in poverty and the public expense of caring for these populations will only increase. The current IHSS program is fragmented and is not conducive to standardizing an equitable living wage for providing healthcare benefits or for training across this industry, which is why we are pushing for statewide collective bargaining.

This change, albeit large, will result in a streamlined bargaining process and will further professionalize the IHSS workforce.

I would be remiss if I did not note that today as we sit here, Congressional leadership is pushing forward a deadly vote, one that will in motion cuts to Medicaid and no doubt threaten the health and well being of seniors and persons living with disabilities.

So while we continue to fight against those cuts, we must also continue the charge ahead to move towards statewide collective bargaining because the needs of the populations that rely on the IHSS program will not go away and the needs of caregivers to live and work with dignity will not go away either.

Before I continue to discuss the need for moving to statewide bargaining, I would like to take a step back to briefly discuss how we got here. The track to statewide collective bargaining was tried before and established by legislation in 2012 through the CCI.

It was a pilot program launched in seven counties with a very limited scope of bargaining that proved to be complicated and ineffective. The CCI also established the IHSS County MOE which redefined the statutory requirement portion of the non federal share for IHSS to be paid by counties.

In 2017, we increased the state participation cap on IHSS provider wages and benefits to $1.10 above the hourly minimum wage. We expedited the flow of 1991 realignment dollars to counties which can be used to pay for wages increases and allowed for mandatory mediation during the negotiation process.

In 2019, we struggled with counties not settling contracts after years of negotiations, years of negotiations with some of these contracts or some counties simply not ever establishing a contract at all. So we enacted a 1% fiscal penalty against counties that refused to bargain in good faith.

In 2021, we established a 7% withholding of 1991 realignment funding for counties who continue to bargain in bad faith. We preserve the cost sharing ratio for locally negotiated wage increases as 65% paid by the state and 35 paid by the county and we maintain the state participation tool that allowed state to partake and up to 10% over three years of locally negotiated wages and benefits increases.

In 2023, we increased the fiscal penalty for counties who failed to bargain in good faith to 10% of the 1991 realignment funding applied on an annual basis this time until a contract is reached. And finally, we agreed to a work group with various departments and stakeholders to examine the shifting to statewide collective bargaining.

Even with all of these attempts to make incremental changes, we still lack proper wages, benefits, training, dignity, and the recognized professionalism that IHSS caregivers deserve. We sincerely appreciate all those that were on the workgroup to discuss this important shift from 58 county bargaining to statewide bargaining.

While the report will not include recommendations, I would like to highlight a couple things that came up that should be considered. We absolutely agree that consumers should have a voice in the process. We propose establishing an Advisory Committee that would include consumers.

With no less than 50% of the Committee being made up of current or former users of the program, there is currently no precedent for having consumers of the program at the actual bargaining table. This would be consistent with how things are currently done with our state workers and our childcare providers, both of which bargain with the state.

Related to the role of counties and given their continued involvement in the program. As we shift to statewide bargaining, we would recommend the counties and public authorities also become Members of the Advisory Committee.

Also, to continue the original intent of the MOE to limit the financial impact to counties when I hss costs increase due to caseload and hours per case growth. We would ensure the county MOE continues to work in a manner that counties can anticipate their costs, accounts for inflation and needed adjustments to the methodology.

The shift to statewide collective bargaining is important for consumers, providers and the state. Shifting to statewide bargaining will be costly, but it is an investment that should be made to continue to save the state. Money will show the state's values are aligned with supporting an essential workforce and will help provide services to our aging and disabled population.

We have a simple request of $1 million ongoing to get things started by hiring staff at DSS and CalHR and would request your support on this appropriation. Thank you so much.

This is a speed talking contest here. Thank you, Chair Jackson. Okay. Sorry about that. Okay, Kristina Bas Hamilton Here representing UDW United Domestic Workers, representing 200,000 IHSS providers in 21 counties, including the wonderful County of Riverside. What can California do to strengthen the IHSS workforce and meet the needs of the future?

I'm adding on to the excellent testimony by my colleague Tiffany Whiten, the Provider workforce crisis is clear. Everyone has talked about that today. I'm not going to belabor it. What I will tell you is a real quick snapshot. 740,000 IHSS providers. This is a massive population.

We know the 60% live with their clients, 73% are related to their clients, 3/4 are female, and a quarter speak a language other than English. We know that they're twice as likely to live in poverty. The annual median wage of all this is caregivers in General is about 24,000 annually, compared to 57.5 thousand for other workers.

And we know they're more likely to work part time. So let's talk about what's driving the shortage. We first and foremost have to be talking about wages. So we know the state minimum wage in California right now is $16.50. Right now. Wages for IHSS vary across the county.

We know that in counties like Siskiyou, they are paid the minimum wage, $16.50. We know in Alpine and five other counties, they're paid $17. We know in Kern and five other counties, they're a little bit ahead. They're at 17.10. And we know the highest county is San Francisco at 22.

The average wage being $18.20, which is far below the estimated necessary living wage of $28.72, according to MIT, for an adult without children. If you had children, that would actually be $51.15 in the State of California. So let's talk about health benefits. Only 16% of IHSS providers get health benefits through their contracts with the counties.

We know through the UC Berkeley Labor center report, only 16% get benefits. And we know 67% of those 16% come from three counties. That's Los Angeles, San Francisco and Santa Clara. Vast majority of the state does not.

We also know from the PPIC report on caregiving that 30 to 40% of caregivers around the state rely on safety net programs like Medi Cal. We don't actually have the data on how many of our workers are on Medi Cal, but I can tell you anecdotally, it's the majority.

No HSS providers, except maybe a tiny population in one of the Bay Area counties gets any kind of retirement security or savings or anything like that. So what does that mean? As the Assemblymember Haney mentioned when we had a hearing on our Bill a couple weeks ago, every county does something different. None do enough.

Workers are winners or losers, depending on where they live, and it's not for lack of trying. Both unions have engaged in serious, serious campaigns to try to incentivize county supervisors to elect to invest in this vital workforce for years and years and years. Ms.

White and has said all of the things I can tell you that as of today, April 2025, Orange County has offered 11 cent increase to its workers that we represent. But that 11 cents would come from a decrease in the health benefits. That's Orange County today. We know that Stanislaus county has offered us 35 cents.

We know Madera County has refused to even come to the table since 2022 saying that they have no money. The average turnover rate of IHSS providers should not be shocking. It's in the UC Berkeley Labor center report. We're looking at 24% for providers who aren't related to their client. For family providers it's about 12%.

Let's talk about why that might be. Well, if I was living in Yuba County, I could work at Kohl's as a part time sales associate with a salary range of 16.50 to $23.85. Kohl's. Let's see what Kohl's offers people. They offer PTO vacation buyback program, parental leave, medical, dental, vision and other short and long term disability programs.

401k flex spending accounts. Let's talk about the Home Depot. In Orange County starting pay is $20 to $23 and you get medical, dental, vision, vacation, six paid holidays per year. You actually are eligible for maternity and paternity leave. It's not a science why these people are leaving these positions.

It's extremely hard work and it is less pay than you could get at other positions. We know that high turnover greatly disrupts the quality and continuity care for consumers.

I'm going to tell you that my one dispute with the CDSS report is that it says that it is not clear whether low wages lead to the workforce shortage or the turnover. I'm going to tell you that it's common sense that people leave jobs because they don't get paid enough.

And the thing that we can use as a factor is to constantly look at the number of authorized hours that a client is eligible to receive through the county versus the actual paid hours.

So this is what the social worker determines a client is eligible for, eligible for versus how many hours they actually are get worked by a worker. And that percentage disparity continues to increase. Specifically after Covid increased drastically. That is telling you we don't know for sure, but I would bet that that's probably a lot.

A reason being clients are not finding workers to work those hours for them and a host of other reasons. I have some of that data as well. I know I'm going over time, I'm going to stop talking. But I have one last thing to say. Caregiving crisis is statewide problem that needs a statewide solution.

Decision making needs to be made at the state level rather than the local level. Decision making on what is good for California as a whole, not based on what is good for the region. Why?

Because county supervisor supervisors are motivated by their local priorities, their local economics and their local politics, which plays a significant role in what is going on in the vast majority of these counties. So since we're talking about this as a statewide issue, which it is, that means we need a statewide solution.

We need state policymakers who have a macro view of policy across the board who understand that IHSS is a continuum within the LTSS spectrum and that the impact on IHSS is the impact on California seniors overall. And I will say one last thing.

There is also a lack and a disincentive for counties on the IHSS spending because counties have share of costs in ihss. They do not have a share of costs in hospitals, emergency rooms and all of the other more expensive form institutionalization of where these seniors and people with disabilities go when they don't have ihss.

Therefore, they are not incentivized to choose the most cost effective service because they are not on the footing the Bill for the more expensive service. So there's a fundamental fiscal misalignment. Thank you. I will stop talking. Thank you very much.

Thank you. Hi, Justin Garrett with the California State Association of Counties representing all 58 counties. Thank you for the opportunity to participate on this panel and talk about the county perspective related to the IHS collective bargaining report. I want to thank the Department for their Leadership collaborative approach to leading this report and workgroup.

And it was clear that the collective commitment from everyone involved in the work group in terms of strengthening the IHS program for counties. We were represented on the work group by CSAC as well as the County Welfare Director Association and the California Association of Public Authorities.

Our engagement on the concept of statewide bargaining came from a collaborative approach to support the IHS caregiver workforce.

And we provided our input in the broad framing of if collective bargaining were to transition to the state level, it must do so in a way that maintains the consumer driven focus of the program and that mitigates any financial, administrative or legal implications for counties.

And so I'd like to cover a few of Those things that we raised in the process. So as you know, state and counties currently share the non federal portion of costs for the IHSS program.

Counties pay their portion through an annual maintenance of effort as well as a share of costs in any locally negotiated wage and benefit increases that are agreed to within the context of county realignment funding that is also used for health and mental health programs.

So we believe that if collective bargaining were to transition to the state level, that the state should be responsible for the non federal share of costs for any wages and benefits that are agreed to as the state would be solely responsible for agreeing to those costs and counties would have no ability to manage it within the associated county budgets and realignment funding.

Counties have maintained a strong commitment to the IHSS program by investing over $100 million in county funds for wage and benefit increases in the last fiscal year alone. These investments were done in recognition of the importance of supporting the IHSS provider workforce.

However, it's important to understand that counties ability to support increased wages and benefits has become strained. So the UC Berkeley labor center report that was referenced earlier and it was commissioned by CDSS as part of this larger analysis, points to a couple of these fiscal pressures that are on counties.

County IHSS costs are growing at 6.5% compared to realignment revenues growing at 4.6%.

The report from the UC Berkeley center also acknowledges that if counties had a share of costs in statewide collective bargaining that would result in less funding for health and mental health programs that are also funded within realignment and so concludes that, you know, it would be significantly challenging to utilize realignment revenues for any county share within statewide bargaining.

Second, we also believe the state should fully Fund the cost of any new mandates or increase county and public authority workload that results from items agreed to in statewide bargaining. Again, the same concept here. The counties would have no ability to control these the the scale of the new administrative costs.

And so from what the state agrees to under statewide bargaining. And then the third key point we raised is that many of the administrative functions performed by county social services agencies and public authorities support both consumers and providers within IHSS and are not currently bargained at the local level.

So these are things like payroll processing, provider registries, backup providers and provider orientations. Continued legislative and departmental oversight over these administrative duties is appropriate rather than inclusion within the scope of bargaining. It's also essential that these core duties remain with public authorities even if bargaining is transferred to the state level.

And that way you continue to get that local consumer input for decisions at the local level that occurs through advisory committees and things like that. So our associations, we maintain a collaborative approach to statewide bargaining and work group and legislative discussions.

And we've outlined these critical county and public authority priorities that need to be considered in this significant policy deliberation. We look forward to continued conversations with the Legislature, the Administration, IHSS provider unions and IHSS consumers. Appreciate the comments from

Ms. Whiteen earlier about our ongoing conversations related to AB283 and appreciate their openness to listen to county concerns and make progress on that legislation. And thank you again for the opportunity to share the county perspective at this hearing.

Thank you very much. We are going to some of you are just follow the direction of our Committee staff who will rearrange our panel.

[Background]

[Background]

Good afternoon and thank you Assemblymember Jackson for this opportunity and other Members of the Committee. I'm Janie Whiteford. I'm the President of CICA, which is the California IHSS Consumer Alliance. And CICA is a statewide membership organization of 26 county IHSS advisory committees and governing boards.

We are state mandated to give recommendations on the IHSS program program to all entities involved in its functioning. These committees must have majority IHSS consumer Members. CICA supports these committees with various resources and educational opportunities. We also see CKA as the voice of the IHSS consumer.

CICA was involved with two other IHSS consumers in the Committee looking at statewide bargaining. IHSS consumers are the employer of record for hiring, managing and if necessary, firing their providers. The consumer also signs off on the provider's time cards. The public authorities are the employer of record for bargaining for wages and benefits.

We are very supportive of providers receiving the best wages benefits possible. Anything which supports the providers also supports the consumers. This relationship is very intimate and dependent on the skills and goodwill that both partners have.

The goal of the relationship is to be long lasting, successful and supportive, allowing consumers to remain in their homes and out of institutions. While we recognize the importance of collective bargaining for wages and benefits from providers, we are very concerned about the negative impact of moving collective bargaining from the county to a state model.

We are concerned about the loss of the consumer voice and control if bargaining moves to the state. This move would make the program more provider driven than consumer driven. Prioritizing provider interests over consumer interests.

Recognizing the importance of bargaining, it will remove local control at the county level for management of the program and place it in a centralized decision making entity. Local advisory boards would lose any influence they have over labor related issues. A statewide advisory board would be difficult to implement.

Not to mention having very little nuanced knowledge of local issues. CICA is pleased that the Committee included the importance of consumers being involved in the bargaining process. Not sitting in an Advisory Committee, actually sitting at the table. Consumers are adamant that providers have decent wages, medical benefits and auxiliary benefits.

Consumers are also aware of issues that are not often considered negotiable items that might improve the workforce environment. This not only will improve the available pool of qualified workers, but also ensure the longevity of the relationship. California is a very diverse state with wide differences between economic, social, social and geographic issues.

Local bargaining and control can take into account these differences. There is widespread variation in wages, medical benefits and auxiliary benefits across the state. We are very concerned that those counties benefiting from successful bargaining could lose ground to those counties that have not been as successful. The local public authorities have legally mandated functions.

The possibility of a statewide public authority taking over some of these functions is particularly concerning. The current public authorities have the ability to adjust to local conditions and needs. The consumers working with the PAS have had success in recruiting more registry workers in some counties. Recruitment will be a huge need in the future.

As our population ages, family Members will always be there for their loved ones needing care to remain home. However, it is wages and benefits and the quality of the job that is most important to everyone. Training opportunities are vital for all providers. The success of the Career Pathways Program attests to this.

We also believe training for consumers can be help help with recruitment and retention of providers. Strengthening the local advisory committees so they can work with their Board of Supervisors to leverage wages and benefits for the best possible outcomes for providers should be looked at.

Consumers and family Member providers make a difference Explore the impact of differential wages IHSS consumers consider themselves partners in the IHSS program at all levels. CICA and consumers look forward to working with the state public authorities, local governments and unions to improve the IHSS program for everyone and remain the premier LTSS program in the United States. Thank you for this opportunity.

Good afternoon Chair Jackson and Subcommitee Members. My name is Kate Laddish. I'm an IHSS Consumer and Chair of the Yolo County IHSS Advisory Committee and thank you for your close attention to this really important topic.

Nothing About Us Without Us is a central tenet of the Disability Rights and independent living movements in Home Supportive Services arose from these movements and is structured around the principle that people with disabilities must be included in making the decisions that affect us. IHSS is the most cost effective way of providing long term care.

IHSS public authorities and the IHSS Advisory Committees are intrinsic parts of this whole fabric. The goal of IHSS is to help qualifying people with disabilities remain safely in their own home rather than go into institutional care. As the employer, the consumer handles the hiring, training, scheduling and when needed, firing of their providers.

The centrality and importantly agency of the consumer is consistent with the program's founding philosophy. The goal of IHSS public authorities is to make the IHSS program work better for consumers and providers.

Local public authorities meet this goal by creating the provider registry and establishing a referral system to connect consumers in need of a pre screened provider and that's especially important for those of us who don't have a family Member as a provider, helping consumers understand and manage their employer responsibilities, providing training for consumers and providers, managing health benefits for eligible providers and giving consumers a voice in how IHSS services are provided via the Advisory Committee.

The public authority serves as the employer of record for purposes of wage and benefit bargaining. Then the goal of the IHSS Advisory Committee is to give the county's consumers and providers a voice in IHSS and public authority policy, program development and operations in Yolo County.

This is done by advising, advocating and making recommendations for the enhancement, availability and quality of IHSS and by promoting services that support a positive and productive relationship between consumers and providers. By law, IHSS advisory committees are consumer majority bodies which is clearly consistent with nothing about us.

Without us, we can and do engage with our boards of supervisors and advocate for programs and funding that strengthen the program and supports the consumers and providers. This Bill would move Administration and control from the local level where the consumer majority advisory committees can have programmatic input and move that up to the state level.

I'm concerned that this would largely negate the input of the advisory committees which are under the local public authorities. It would decrease the voice of California's approximately 800,000 plus consumers having consumer seats on the statewide Advisory Committee that makes more of the non binding recommendations. I'm concerned that this might move the consumer voice more to the periphery.

In this way, the Bill would fundamentally alter the IHSS equation and move away from the program's nothing about us without us roots. I urge the Subcommitee and partners to consider how to maintain the consumer or disability voice which is often best heard locally, and how to stay true to IHSS's central philosophy.

I and other consumers have tremendous, tremendous respect and admiration for and gratitude to providers. After all, providers care is how IHSS's goal of avoiding institutional care is met. And I think it'd be hard pressed to find a consumer who doesn't think that providers don't deserve to be paid heaps more.

So I want to be clear that there's no competition or something between consumers and providers. There's no us versus them with this.

After all, so many consumers and providers are family Members and even if you're not, the individual consumer and provider team is so rich and it's so central to this program's success and providers and consumers want their colleagues and their partners to get all available support.

What we find in Yolo County is that frameworks are programs that help keep or that keep in mind the goal of IHSS and the often linked needs of consumers and providers are often better poised for success than programs that focus on only one of the partners.

For example, in 2021, when our Board of Supervisors put out a call for ideas of how to spend American Rescue Plan act funds, our Advisory Committee successfully advocated to secure $200,000 for paid professional development training for providers. Why did we choose this? Two reasons.

One, training providers helps them take effective care of consumers, which will help consumers remain safely at home.

And avoiding congregate care is not only the goal of I particularly important during a respiratory pandemic, and then also too everyone on the Committee, consumers, providers, community Members as well as staff understands the importance of supporting providers financially and by treating them as the deeply, deeply valued professionals that they are.

Our Committee is also considering that training for consumers on how to hire and supervise providers, be they family Members or someone from the registry, could help consumers connect with providers. And it would. It would help consumers get care. It would also help providers get work.

As an aside, I actually, as a consumer, I find it more daunting to hire a new provider than to come up to the fourth floor of the State Capitol and testify before you this afternoon. So, so training would be great. So local knowledge is needed to solve local problems.

For example, just looking at a map of Yolo County, you wouldn't guess that it's much harder to get a provider in one of our four cities than in the others.

However, with a Local Advisory Committee and local public authority, you can learn from consumers that it's a problem and learn from providers that a lot of the problem is due to a perceived notion of remoteness of that fourth city. And so then we can work locally to make that happen.

Serving on an IHSS Advisory Committee is the first time that having disabilities that my lived experience has been treated as an asset rather than a liability or something that I would be expected to hide. This has been revelatory. I can't underscore enough what a difference this has made for me. I don't have to be apologetic.

I can just be me. And serving on this Advisory Committee has then been a direct springboard to being able to take on other opportunities that are linked, such as serving on my county's Voting Accessibility Advisory Committee and being appointed to represent Yolo's IHSS Advisory Committee on the state's Emergency Standardized Emergency Management System Alerts and Warnings Specialist Committee.

And so then I could take the IHSS perspective and the disability perspective and write that into the state's new alert and warning guidelines and that I could do that because of serving on the IHSS Advisory Committee. So I respectfully request that we consider two additional questions to the excellent ones posed to our panel.

One, will the proposed changes help realize IHSS's goal of allowing people with disabilities to live safely at home, specifically how or how not? And two, are the proposed changes in alignment with IHSS's founding nothing about his philosophy? Thank you to the Subcommitee and very heartfelt thanks to California's IHSS providers.

Department of Finance Idalys Perez so we want to raise an important point when considering the cost estimate shared by the Department that there's significant uncertainty on the cost for a potential statewide collective bargaining system because it depends on many variable factors.

The estimates cited by the Department are point in time estimates based on specific assumptions and different assumptions would result in different costs.

For that actual costs would actually depend on negotiated wages specifically for the potential increases and benefits, as well as actual growth rate for IHSS recipient caseload Updated hours per case, updated cost per hour, along with any federal funding policy changes, as well as any cost sharing between the state, counties and overall could be upwards of billions in additional state General Fund costs.

These additional costs are on top of the estimated growth in the program costs based on the normal caseload changes we're seeing.

Thank you very much. LAO

Juwan Trotter, Legislative Analyst Office so as we heard from the Department, the IHSS collective bargaining report is set to be released Friday.

So once this report is made public, we plan to thoroughly review the report and be able to provide technical assistance as we work through the understanding the contents of the report as well as some of these cost estimates that the Department has brought up just now.

In addition to the rest of this report, we have identified some additional cost pressures for the IHSS budget overall that we thought would be good to bring up at this moment. So overall we do believe that the IHSS budget does appear to be reasonable.

However, there are some costs pressures that have not been accounted for fully in the Governor's Budget. So first, the most up to date caseload data does show that monthly caseloads have been running higher than what was estimated in the Governor's Budget. We do believe that this will be updated after may revise.

However, this does show that or suggest that IHS costs may be higher in 25-26 than what was estimated in the Governor's Budget. Additionally, the Governor's Budget also estimates that the average number of monthly hours Per case will remain the same in both 24-25 and 25-26.

However, historically, we have seen that the average number of hours hours per case has consistently grown year over year. So the Department has noted that they're tracking these trends. But should this trend continue? This is another source where I just cost maybe higher than 2526 than estimating the Governor's Budget.

And then lastly, as was noted earlier in the, in the panel, the IHSS Career Pathways Program, that program is currently reported to have a funding gap of about $24 million. And so that also was not addressed in the Governor's Budget.

Obviously, this is an important issue and we wanted to highlight just how important this issue is to the Legislature because we do need more stability, predictability, reliability in this system. And it has been increasingly concerning, even in my own county.

The fact that we are taking so long to come to agreements, refusals to be at the bargaining table altogether, and the only people that lose are the people of California.

We have got to figure this out, which is why many of us believe that a statewide bargaining is the way to go to ensure that we have more consistency and reliability. Now, I am a trained social worker, and there is no doubt that clients are experts in their own lives.

And it's not our job to tell you what is best for you. It is for you to tell us how we can best meet your needs. And so it is my hope that as we continue to go through this process, which I hope becomes a more productive and healthier process moving forward, we've got to get this right.

Yes, I know there's cost pressures. I know there's a lot of things to consider. But I think the more we delay coming to an understanding, coming to agreements, everyone being on the same page. People. Are going to be hurt. And so we'll continue to have this panel as many times as we need to.

We're not going to allow this issue to die down. I look forward to reading More thoroughly the LAO's reports on these, on these, so I can dig a little deeper. But certainly we want to make sure that everyone is at the table.

We want to make sure that everyone is treated with the dignity and respect that they deserve, that professionals are treated with the professionalism that they deserve and the many thanks that they deserve for even accepting the service, to provide the services at the cost that they do.

And I look forward to working with my colleagues as we continue to move both through the budget process regarding this issue and the legislative process as we go through this issue. So as you know, we would have many more colleagues here, but we're all trying to find every last vote we can to get our bills through.

And so, quite a busy time, but thank you so much. Out of order. Out of order. Have mercy with that. This issue's done. Thank you all very much. Thank you all very much. Okay, we are going to recess for about 30 minutes.

So we're going to keep. We're going to keep running through this baby so we can get everyone. It is my hope to see the sunset. It is my hope. I've only seen the sun once today. Why don't we bring up the next panel issue, please?

Issue number four, Issue of number four, and I think this one is a rather smaller panel. Department of Aging and we already have Finance and LAO and you may begin when you're ready, sir.

Hello again, Chair Jackson. Mark Beckley, Chief Deputy Director, California Department of Aging Glad I didn't have to delay my testimony on this important topic. So Developing an aging and disability nature wrong door system is a key component of the California Master Plan for Aging.

The no wrong Door system would build upon the existing Aging and Disability Resource Connection Network, which is a collaboration between the AAA's local area agencies on Aging and Independent Living Centers.

So both disability and aging working together to assist older adults, persons with disabilities and caregivers to find the services and supports in their communities and and discuss their service options with experienced aging and disability resource navigators.

In terms of steps to implement a no wrong door system in 2024, CDA hired a consultant to research best practices in other states for the development, implementation and operation of an aging and disability no wrong door system in California.

Drawing upon a federal grant award that we received in 2022, CDA also established a Disability and no Wrong Door Award Leadership Council consisting of CDA and the Department of Rehabilitation as CO leads, as well as the Department of Healthcare Services, the Department of Social Services, and the Department of Developmental Services as our partners on this council.

The purpose of the State Leadership Council is to develop policy, procedures, operational standards and infrastructure to support a no wrong door system. In our research, we found that no wrong door systems generally consists of four key components.

The first is a website, a central statewide website that contains information about aging and disability programs, including a directory of local service providers that are searchable, usually by zip code and search type. So if you've seen, say, the 211 websites similar in design and feel to those.

Second is skilled aging and disability resource navigators who can discuss service options with customers and connect them to local service providers.

Third is a statewide provider network that can provide individuals with the services that they need and then finally, branding that is readily understandable and identifiable by the populations that we serve, as well as a robust outreach campaign to publicize the new system.

In addition to establishing the State Leadership Council, CDA took a first step towards addressing the third component of an orangdor system which is the provider network.

So leveraging $5 million in home and community based service funds, we established a statewide data repository at CDA to contain information about all of the aging programs that we oversee, as well as ready to ingest in information from other departments as well.

We will use this data to understand the needs of the populations that we serve, assess service capacity, need for growth in different areas, as well as service gaps that need to be addressed throughout the state. By the end of 2025, the day repository will contain information about our Older Americans Act programs as well as our Ombudsman program.

And then over time we we will continue to populate that data repository with additional program data. So we are also currently researching and evaluating options to define the requirements for the base components that I spoke of and to really determine what a no wrong Door system looks like and would best serve the people of California.

Regarding the second question about whether there's a need for legislation or MOUs for the system, we don't think that legislation is necessary to establish the system. The system could be established administratively in the state. However, MOUs could be helpful over time as we engage in partnerships with local partners, whether it's IHSS agencies or housing transportation agencies.

These MOUs could provide clarity in terms of the roles and expectations that partners in the no Wrong Door system would be expected to follow, and it would also help further collaboration with other partners as well. So in a nutshell, that is what we're looking at for new wrong Door System.

Jennifer Ramirez from the Department of Finance. Nothing further to add.

Juwan Trotter, Legislative Analyst Office so given the information that CDA has just presented on the no wrong Door system, we can follow up and work with the Department to kind of further solidify some next steps for this initiative.

So obviously, a lot of times I think since I've been here for three years, I've always heard no wrong door is so important. No wrong door is so important. I hope we get there. I hope we get there one day. It's possible, right? But I don't see sometimes tangible things being done with clear benchmarks.

Well, when are we going to get there? Right? Which departments are we going to work with first? Which population are we going to work with first? Is it the foster care who needs the same thing? Is it people who are eligible who are in CalFresh and CalWORKS? Is it our aging population? Right.

What I'm looking for is to start putting together some clear goals to be able to meet in some clear actions to be able to do that. Now what I am happy is hearing is that, well, I'm not sure if I'm happy. I'm a Legislator. So you said there is no legislation that needs to be done.

I think that's blasphemy, but don't let that ever be your recommendation. But I think the idea is that whether we don't need legislation for departments to automatically do it, it seems to me that we might need some legislation to mandate it, that it happens by a certain time.

Again, we are in a mode where a lot of great work has been done under this Administration, but we need to. It's time for the Legislature to pick up the slack because we won't know what the Next Administration is going to look like and what their priorities are going to be. So the more that we can begin to codify these things, the better.

And I believe in a past hearing I also already requested for the LIO to help us with what are some concrete steps we can take that the Legislature can take to begin and provide a roadmap to ensure that we're truly implementing a no wrong door approach. What type of mouse do we need to do?

What type of legislation would you recommend that we do? Because certainly it's a clear problem that I think we all agree with, but we've yet to really get our allow the public to understand that. Yeah, we understand it and this is how we're going to fix it.

And so we're going to continue to work on no wrong door issues. For. As long as we need to, as frequently as we need to. But it's time to actually put some clear action plans around this.

Certainly thankful for the whole person approach that the Department of Aging is taking and understanding all the different departments that are responsible for the same person. Have mercy. Right.

And all the different forms that each one requires, all the different hoops and offices and Lord, please make sure that all those people who have different offices are in the same city, right, or next to each other and that you can see them in the same day. Right.

All of those things are so, so, so important to be able to get there. So thank you very much. I look forward to continuing to looking forward to the recommendations of LAO to help us kind of understand or get our hands around this. Thank you so much, sir. Thank you. Okay, we're moving on to issue number five.

And many of you are veterans of this process. And so you know that at any given time I could be called away to do something else and in which I will have to recess. I Hope none of you made any plans. Cancel that date right now. All right, we're moving. Issue number five. We're actually almost. We're almost there. Issue number five. If I stop talking, you may start.

Thank you. Dr. Jackson. Pleasure to be here. My name is Danielle Morris. I am the chief over the fiscal appeals and benefit programs within the Department of Social Services. And I'm here to speak about the Supplemental Security Income and State Supplementary Payment, SSI and ssp, respectively.

These programs provide a monthly cash benefit to adults 65 and older, blind and disabled Californians. SSI is federally funded and SSP is funded by the State General Fund. First, I'd like to highlight the growth in grant levels since 2009 for individuals that are age or disabled, which is our most common payment standard.

Their SSI/SSP monthly payment has increased from $907 a month in 2009 to $1,206.94 a month in 2025. That's an increase of 33.1%. The SSI/SSP payment amount for individuals, however, is still below the federal poverty level by 7.5% as of January of 2025.

For couples that are aged or disabled, their SSI/SSP monthly payment has increased from $1,579 per month in 2009 to $2,057.83 per month in 2025. This is an increase of 30.3%. Their SSI/SSP payment amount for couples is above the federal poverty level for a household of two by 16.8% as of January of 2025.

In terms of the state COLA, I'd like to just touch on the significant investments to SSP grants specifically since the cuts were replaced in 2009 and 2010. In January 1st of 2017, there was a one time COLA of 2.76% applied to the grants.

In 2021, there were Golden State Grant payments of $600 which were provided to SSI/SSP recipients as a one time payment. The most significant increase occurred January 1st of 2022. There was an investment of $291.7 million to the grants which increased SSP grant levels by 23.95%. And then there were two subsequent increases to the SSP grants.

On January 1st of 2023, there was an investment of 150 million, resulting in an increase of 10.3% to the grants. And then in January 1st of 2024, there was a further investment of 146 million, resulting in an increase of 9.2%.

The Department has calculated what applying a COLA would be for the SSP grants beginning effective January 1st of 2026. CDSS uses the California Necessities Index, CNI as opposed to the Federal Consumer Price Index, which are applied to the SSI grants. The CNI of 3% from 2024 would result in an estimated increase of 54.5 million General Fund.

That's half your cost being applied effective January 1st of 2026. And for ongoing, that would be 108.9 million General Fund. And that would be taking.

Did you say 108 or 109, 8.9.

108.9. Yes. Yes. And then looking at the COLAs that would have taken place if they were not cut in 20 in 2009, as well as looking at the look of the fair market rent today. The Department does have table displays within our local assistance binder in our reference documents.

We're happy to provide that that provide a look of the state cost of living increases to the SSP grants if they were not cut beginning January of 2009 and each year thereafter. I can tell you what the differences are.

So if there were no cuts and COLAs were applied each year, maximum grants for SSP individuals would be $391.51. For couples it would be $961.72. That's a difference of $154.57 for individuals with the grant amounts today. And then for couples, that would be $353.89 of the difference compared to the fair market rent values.

This varies county by county, but the Department also does provide a display in the reference documents as a comparison of current grant amounts compared to fair market rent.

What I can tell you is for individuals receiving the maximum grant amount of $1,207, there are 26 counties within the 58 throughout California that this grant amount would not be sufficient to cover the fair market rent. For couples receiving the maximum grant amount of $2,058.

There are 16 counties within the 58 that would not be sufficient to cover the fair market rent. That concludes.

You can still finish. I mean, I got it. I got it too. So, you know, I say we just ignore it at this point.

If you're. Okay. The only thing I was going to point out, just a few of the counties that that applies to are some of the higher counties. Alameda, Marin, Monterey, Orange, San Diego, San Francisco, San Mateo, Santa Clara and Santa Cruz, just to name a few.

Thank you very much.

Hello, Chair Jackson. My name is Rebecca Gonzales and I am speaking on behalf of the Californians for SSI and the Western Center on Law and Poverty. Californians for SSI is a statewide coalition of organizations and individuals against the aging, disability rights, housing and homeless, anti hunger and anti poverty sectors.

We advocate to provide sufficient funding to California's 1 million SSI seniors and people living with disabilities so they could reach economic self sufficiency, rise above the poverty level and live with dignity. SSI and SSP is a life saving cash benefit for low income older adults and individuals with disabilities, including children with disabilities.

State leaders must remain committed to protecting and finding opportunities to strengthen grant levels, especially as many programs SSI recipients rely on are under federal attack. To start, state leaders can ensure that SSISSP grants regain the purchasing power they have lost over the years by restoring the yearly cost of living allowance.

This will help with the affordability crisis impacting recipients of this grant which is currently inadequate. While rising prices on basic needs affect everyone, they have the hardest impact on people with low incomes. Additionally, low income individuals across the state are rent burdened and 1 in 5 Californians struggle with food insecurity.

Rent continues to rise faster than the grant levels. Today the fair market rent for a studio apartment is more than half of the SSI individ Grant in all 58 counties and rent is higher than the entire grant in 28 counties. Currently, 60% of SSISSP recipients live in 14 counties with the highest fair market rent.

Having an automatic cost of living increase on the state portion of the grant to match the automatic COLA that exists for the federal portion will ensure that the grants can keep up with inflation and other unexpected cost pressures. It will also keep people housed which is a major concern for individuals and the community at large.

In addition, this program is the only state basic income program that does not receive an automatic COLA. Secondly, we also need to raise the grants up to at least 100% of the federal poverty level where they were before the recession. This will help recipients afford rent and food at today's prices and then reduce senior homelessness and hunger.

We appreciate the SSP grant increases that the Legislature has championed in recent years. However, it is important to acknowledge that the recent increases just bring the real value of the grants to somewhat above where they were after the recession era cuts.

At the end of those cuts in 2009 and 2011, the individual grant dropped to 91.5% of the federal poverty level and today that individual Grant is at 92.5% and projected to be 90.45% of FPL in 25-26. Basically, even though we got back the specific dollars lost in the recession, we lost a lot to inflation over the interven years.

After years with no COLA and no grant increase, we know real costs here are well over 100% FPL considering health related costs and additional costs related to disability and in the future we should aim to Fund grants at the elder economic index level, but in the meantime let's at least get the grants there first.

Raising the grants to at least the federal poverty level will help people to sustain their lives. Also provide more economic stimulus and local communities which is where low income older adults and individuals spend their money. Every 10 million in increased SSP payments would support 15 million in economic output.

That's a multiplier of 1.593 jobs and 0.9 million in state and local tax revenue. Therefore, we request a five step increase to bring and keep the grants at 100% FPL and spreading that out over five years because it is a significant amount.

I want to point out in the agenda the Administration's budget numbers reflect decreases for this program over the last two years because of a slower caseload decline than anticipated and lower average grants. We hope the Committee will look at these cost savings and reinvest them in the program.

Lastly, we should support older adults and people with disabilities when they face emergencies by reinstating a program to support recipients when emergencies arise.

However, unlike many, it is nearly impossible for folks on SSI to save for emergencies due to the low grant levels making it difficult to meet day to day needs, let alone save for the future, especially with high rent and due to the SSI asset limit of 2,000 for an individual and 3,000 for a couple.

Reinstating this emergency grant program that is still in statute would provide a lump sum of funds to an ssi, IHSS recipient or those on CAPI.

People could use the funds for a variety of reasons including for moving costs, to prevent homelessness, to maintain heating, cooling systems or generators, to mitigate the impact of climate change, and to maintain safe and operating stoves and refrigerators to allow SSI recipients to prepare their own food, keep medication cool, save money and maximize calfresh dollars.

Taking these actions would mean that more low income older adults and people with disabilities could have safe habitable housing and have the food they need. Let's do what it takes to ensure that people can live their lives with dignity, peace of mind and economic security. Thank you.

Isabella Aliota Department of Finance Nothing further to add.

Lao Juwan Trotter Lao so as was noted in the agenda, the governor's proposed budget does not include any new proposals for ssissp. However, for the program overall, we are continuing to see a slight decline in caseloads.

And while maximum SSI/SSP grant levels are projected to increase in the budget year, this is entirely due to an estimated federal COLA of about 2.5% applied to the SSI grant set to take place in January 12026. Notably, the proposed budget does not include a state level COLA for SSP grants in the budget year.

And as was noted by the rest of the panel, it is estimated that the despite this federal grant growth, the maximum combined SS ISSP grant level is estimated to remain below the federal poverty level for individuals and slightly above for couples.

With all that being said, as the Legislature continues to think about the SSI/SSP grant levels, we're available to provide technical assistance as needed.

So if you're single, you will have issues, but if you have a partner, you will be better off slightly. What does love got to do with it? You know, this is important to me just because again, the idea is how do we provide, how do we ensure that senior homelessness does not become our next crisis?

And I'm trying to figure out, out of all these different programs, which has the best chance of addressing this issue. Right. Is it the, is it SSI? Is it SSI/SSP, COLAs or 100% of the poverty rate? Is it, you know, the myriad of other housing programs that we have? Right.

Is it things, Is it programs like Home Safe? I know we'll have a panel on that. Which ones should we be focused on? You know, how important is SSI when we're trying to prevent this from being a crisis? What do you think? Because it is a humongous cost, it.

Is a big cost. And as the Western center on Law and Poverty, we do support a variety of programs. But I think what's important about the grant is that it's unrestricted cash, which I think has proven to be very helpful for people to spend the money in the ways that they need to spend the money. And I think that's, that's, you know, key.

Got it. So we should be prioritizing those programs that are more unrestricted. That way they can meet the many needs or prioritize those needs instead of being directed what is best for them to do. Right. Is the. How confident are we that we're going to be able to rely on that federal increase?

I don't have a direct line to the.

Oh, they don't answer my Call either. Trust me. Any thoughts? Department of Finance.

Department of Finance. I think we're in the same boat as everybody here. I mean, it's just. There's just a lot of uncertainty. So not sure at this time.

Okay.

Yeah.

So certainly this is still, we know this is still an important program, would probably offer the quickest way to get money into people's pockets because they're already enrolled in the program. Now it's just a matter of doing a little cash infusion. Do we know how many of those seniors who are falling into homelessness already receive ssissp?

I mean, I don't have that information available now, but we can take that back and see if there's something we can provide.

Lao. Any thought, Any idea?

We also don't have a number at the time, but we can reach back out to your office.

I think that would be a good data point because as we're trying to prioritize. Right. I mean, remember, what we're really trying to solve here is, number one, preventing seniors from falling into homelessness. But also those who are. Have already done so or who are just on the brink.

How much of that population would we capture if we focused on the COLA increase for ssissp? That was a good question. Sometimes you impress yourself, you know. All right, so if you can get those answers, that would be fantastic. Please. Again, trying to navigate all of the different options that we have.

But the most important thing is doing nothing is not acceptable. So I also want to make that clear. Thank you very much for this panel.

Thank you.

Issue number six. Wow. Is the sun still out? Does anyone know? It is. OH, man. We might just make it. And Department of Aging. You may begin when you're ready.

Good afternoon, Chair Jackson. Thank you. I'm Nicole Shimosaka, Deputy Director of Administrative Services at the California Department of Aging. Here to discuss. Discuss the Older California act and Older Americans Act funding and needs. As a state unit on aging, the California Department of Aging oversees and administers the Older American Act and Older California act programs.

These programs provide older adults, people with disabilities and caregivers with resources to support and promote their mental, physical and emotional needs, including supportive services, congregate nutrition, home delivered meals, preventative health, family caregiving and legal services. Annually, California receives approximately $244 million in state and federal Older American act funds.

The greatest percentage of these funds goes towards nutrition services at 68%. Since 2020, CDA has received a General Fund increase of 52 million for nutrition services on an annual basis. This has allowed for an increase of 2 million additional meals each year.

Area Agencies on Aging continue to use this funding to provide a greater number of meals, serve a greater number of participants, address the rising cost of inflation, and address the increased cost of overhead to provide the meals. The next greatest component of funding is dedicated to supportive services at 15%.

Supportive services include information and assistance, transportation, case management, legal services, and more. Throughout the pandemic.

Beginning in fiscal year 2021 with the family First Coronavirus Response Act Fund and concluding this September with the American Rescue Plan act funding, the AAA has received over 250 million in increased older American act funding to support older adults, adults with disabilities, and caregivers at home.

The Department also administered 365 million in home and community based services pilot programs to support nutrition investments, access to technology investments, family caregivers, provide increased legal services, and to modify homes for fall prevention.

In fiscal year 2223, the Department was granted a General Fund investment of 186 million to support the Area Agencies on Aging in ramping down the COVID era funding and service levels in both nutrition and supportive services. This funding provided by the Legislature is designed to alleviate the nutrition cliff created by the increased nutrition funds throughout the pandemic.

These funds will expire in fiscal year 27-28. In 2021, the California Association of Area Agencies on Aging commissioned a study on nutrition needs that points to an unmet need in nutrition services for millions of older adults.

The report highlighted that prior to the pandemic, as many as 842 million meals were beyond the budget of low income older adults. After accounting for the available services during the pandemic, there was an expansion of programs available, lessening the gap to an approximate shortage of still 370 million annual me.

In addition to the Older Americans Act nutrition programs, the Department of Social Services oversees programs that support older adults and help address the statewide meal need. These programs include CalFresh food banks and the adult portion of the Child and Adult Food Program. Nutrition is an area that the Department continues to focus on as a priority.

Further, the Area Agencies on Aging use their Area Plan Needs Assessment to identify other needs within their local planning and service areas. There continues to be a need for rural nutrition services, culturally appropriate meal options, and emergency meals during disaster events.

In addition, we have seen staffing declines in two of our programs that rely on a hybrid paid staff and volunteer workforce. This includes a long Term Care Ombudsman and the Health Insurance and Counseling advocacy program known as HICAP.

Between 2024 excuse me, between 2020 and 2024, the High Cap volunteers declined by 20% and the Ombudsman volunteers declined by 51% over the past year.

CDA has been working on a statewide ombudsman recruitment campaign funded through a federal grant, and we plan to launch this campaign this summer, beginning in July and ending in December 2025 as part of our high cap modernization efforts. We also plan to address high cap staffing.

We plan to send our HICAP report and recommendations within the next two months for your review. Additionally, caregiver services, particularly caregiver respite services, continue to be in high demand across the state due to a lack of affordable and qualified respite providers. Some AAA's do maintain wait lists at their discretion, but this is not consistent across the network.

Our commitment remains in serving individuals with the greatest social and economic needs. With the intent of strengthening the aging network, the Department has embarked on the CA 2030 effort, which aligns with the chaptered Senate Bill 1249. CA 2030 is designed to provide consistency and quality of service in nutrition information and assistance, supportive services and caregiving.

CA 2030 includes a plan to create performance metrics within these three areas for continued monitoring and improvement, which will allow for a deeper dive into unmet needs in these service areas. Further, the Department is exploring the potential of updating the intrastate funding formula, which is the formula used to allocate all Older American act funds to the AAA's.

Review of this formula is intended to ensure that funding is getting to where it is needed most.

Crucially, within the state, the Department continues to work closely with Area Agencies on Aging to create a future ready aging network that will be equipped to provide consistent and comprehensive support and services to older adults, people with disabilities and their caregivers. Thank you.

Good afternoon. Senator Jackson, Great to see you today.

Assembly Member, They have too many rules over there.

Oh my God. Well, thank you. I thought my energy drink was gonna help me.

I would not last one day there. Absolutely.

Thank you. Before I get started, I just want to point out that there's of course a lot of uncertainty on a federal level, but especially for the Older Americans Act, given what's happened with the restructure at HHS and the Administration on Community Living and not knowing where we will be with the reauthorization or the final rule that ACL worked so hard to get to at the end of last Congress.

With that, thank you for the opportunity to speak today. I'm Christina Mills, Executive Director of the California Association of Area Agencies on Aging C4A. I also want to thank Committee consultants for preparing the thoughtful background analysis. Let me begin by addressing two of the questions raised by the Committee.

In response to the Committee's first question, where do we see rising demands for services where providers are not available? Unfortunately, all across California, as the older adult population continues to grow and more people with disabilities live longer, thank goodness, the demand for long term services and supports is outpacing the availability of providers, especially in rural communities.

Geography plays a significant role in many parts of the state, particularly inland and in far northern counties, there simply aren't enough service providers. This can mean long wait times for in home care, gaps in transportation which is already limited, and limited access to culturally competent services such as nutrition.

But even more urban areas, people face barriers if they lack a strong personal support system, struggle with the digital access, the digital divide, or can't afford the rising cost of housing home modifications like ramps or grab bars which can make a difference between institutionalization and safely aging in place are often unaffordable and unavailable.

Caregivers, many of whom are unpaid family Members, are burning out under pressure and they need support too. And I'm sure if you're watching the Pit on HBO, you've noticed that there's some folks walking out who are how.

Did you know I watched that?

I know you watched that. This is where the Aging and Disability Resource Connections ADRCs come in. ADRCs help people navigate fragmented systems by providing a coordinated person centered entry point to services. So when we talk about a no wrong door system we we start with adrcs.

They offer enhanced information and assistance options, counseling, short term service coordination and transition services. All designed to help people who want to stay in their homes and communities independently with support and dignity. They are the systems navigation that you've been talking about today.

California has allocated 10 million annually for ADRCs since their inception, which I was a part of back then.

On the other side of the coin which does not allow for program the program to increase or expand statewide, we are respectfully requesting an additional 15 million in the 25-26 budget to support and expand the ADRC navigation network, especially into regions with no to little coverage.

This is a down payment towards the $62 million needed for a fully built out program that we refer to as the foundation of a statewide no wrong door system that is expected to be prioritized in the Master Plan on Aging. Our state's ADRC model is unique and effective.

It requires a formal partnership between Area Agencies on Aging and Independent Living Centers, ensuring both aging and disability communities are effectively served by experienced professionals and individuals with lived disability experience.

This shared governance helps ensure services are inclusive, accessible and grounded in real, authentic community needs to the Committee second question do AAA's have wait lists or how do they assess unmet needs? Yes, some AAA's do have wait lists, particularly for high demand services like in home care, the caregiving support that Nicole referred to, and home delivered meals.

AAA's assess unmet need through a variety of methods, community needs assessments, client intake, data surveys, outreach opportunities, and frontline service provider feedback. In many areas, demand exceeds supply even when we don't have a list to point to. Providers report growing numbers of older adults seeking services that they can't yet deliver due to funding or workforce constraints.

Nutrition programs are a strong example. Some AAA's have had to ration meals, cap the number of participants, and collaborate with and coordinate with other community providers who might have additional capacity. Thank goodness for those other community providers.

When Covid relief funds began to expire, the state stepped up with additional nutrition dollars through Moca investments, which made a difference. But the need remains and it will grow, particularly as food insecurity among older adults continues to rise.

In closing, California's commitment to aging in place outlined in the Master Plan for Aging hinges on our ability to Fund and expand the infrastructures of ADRCS and core aaa programs.

The $15 million increase we're requesting for ADRCS will strengthen the no Wrong Door system and begin to close the equity and access gaps that still persist across our state. Thank you so much for your time and your leadership and commitment to older adults and people with disabilities.

Hi. Thank you for having me. I am Rachel Tate, a social worker and Vice President of Ombudsman Services for Wise and Healthy.

Where'd you get your MSW?

Cal State San Bernardino. I'm sorry.

Don't be nervous. It's just me and you right now.

Bakersfield.