Senate Standing Committee on Health

The joint informational hearing will begin in 30 seconds. It the joint informational hearing on the federal action impacts on community health will begin. Good afternoon everyone. I apologize this week has been a crazy week. Will be so for the next couple of weeks. So I appreciate your patience here. Welcome to the Members who will join us today.

My co chair here, I thought it was really important. While we do recognize there are 500 symbolic fires that we have to be putting out during this week, we need to remember and continue to have conversation on the ongoing impacts to our health care system.

The consumers, consumers and Californians that depend on the Legislature to ensure that they have access to health care to providers that everything is equitable. So it was imperative that we came together and heard directly from the experts on what is happening or what is going to happen from the HR 1 impacts to California.

What is the intersection and correlation between the raids in California and how it correlates to public health because it is a public health manner and what providers are seeing as a result of both HR1 and the raids. So excited to be hosting here with my co chair.

Thank you. I want to thank our Senate Health Chair for bringing this together and also want to acknowledge that Senator Weber Pearson who subs the Health Budget Committee as well as Assemblymember Don Addis who chairs the Subcommitee on Health on the Assembly side will be joining as well.

I proudly represent Oakland, Alameda and Emeryville and I just want to recognize that HR1 will have probably profound impacts on California's net safety safety net programs, most significantly on Medi Cal. Collectively, the cuts and policy changes in HR1 is projected to result in tens of billions of dollars.

That's a B in reduced federal funding over the next decade and substantially reduce the number of Californians with health insurance. This unprecedented federal disinvestment represents a stark reversal of the progress we've made here in California.

Indeed, this Bill is leading us down a very dark path for more Californians being sicker, more Californians with crushing medical debt, less financial and health security, less connection to screenings and primary care, more expensive emergency Department visits, more moral injury and burnout of our workforce and an overall diminishment of our health infrastructure.

This is all happening at a time where Californians are demanding greater access to better care.

This is simply no way to paper over or correct for this level of disinvestment in our health care system and the effects on our hospitals, health care facilities and health care providers will be felt for every single Californian regardless of whether or not they are on Medi Cal at the same time, it is clear that this Administration, this federal Administration, has created a culture of fear for immigrant families looking to make a home out of California.

It is clear that not even a Doctor's office can be assumed to be a safe space. And federal actions have discouraged immigrant communities from seeking needed care. We know that losing coverage doesn't mean people stop getting sick or needing health care. It will just further stress our health care safety net.

I haven't even mentioned the pennywise pound foolish divestment in our health research and science, the war on vaccines and evidence based medicine dissemination, or the decrease of decimation of federal agencies that safeguard our health and more. The ramifications are profound.

And although we don't have full information about these impacts, about what options we have to be able to respond, I'm very glad and thankful that Senator Mengavar has led us in having this initial conversation across both of our houses so that we can stand united in the State of California and in this Legislature in our advocacy for Californians.

With that, I want to thank our Committee Members from Assembly Health who are joining with us today and look forward to the panel discussions.

Great. This afternoon we will be having three different panels. We're going to do the HR1 impacts on the Medi Cal program. First, after each panelist, we will have questions from each Committee Member. After all three panels are done, we will then turn to the public from any public comments they'd like to add to this conversation.

So if we can get the panelists on HR1 impacts to the Medicare program, come on up. Today we will have a conversation with the Department on Healthcare Services, Planned Parenthood, affiliates of California, the California Hospital Association and the Western center on Law and Poverty. Director Winter settled. You'll kick us off.

Good afternoon, chairs and Members of the committees. Michele Baass, Director of the Department of Healthcare Services. I plan today to provide an overview of the impacts of HR1 to the Medi Cal program. And if I could ask for the slides to be queued, that would be great. Perfect. Thank you.

So Medi Cal serves nearly 15 million Californians, roughly 35% of the state. This includes over 5 million children and teens. It supports adults and individuals with disabilities. It's more than just health care. It's a lifeline for the Californians.

It serves HR1, as noted earlier, makes sweeping changes to the Medi Cal program and will cause widespread harm by making massive reductions in federal funding and potentially cripple the health care safety net that all Californians. I said all Californians depend on these changes.

Put tens of billions of dollars of federal funding at risk and could result in the loss of coverage for millions of Californians. Next slide please in particular, the provisions of HR1 that apply to Medi Cal focus on restricting eligibility and access requirements.

This includes the addition of work requirements, semiannual eligibility redeterminations, restrictions on retroactive coverage and new cost sharing requirements. State financing restrictions. This includes limitations on state funding mechanisms such as provider taxes and state directed payments which are vital to supporting the Medi Cal program. Immigrant Coverage limitations.

This includes reductions in federal matching rate for emergency services for individuals with unsatisfactory immigration status and restrictions on immigrant eligibility coverage and a one year ban on abortion providers receiving federal Medicaid dollars. These changes will impact our emergency departments, hospitals, private and public and rural hospitals, community health centers, ambulance providers, and the broader healthcare delivery system.

Next slide please as you can see, provisions of HR1 go into effect immediately and over the course of the next four years. Again, some of these provisions take effect immediately.

We are continuing to review HR1 and the provisions of this Bill and are planning for implementation of these provisions and I will walk through each of these in a little bit more detail on the next slides. Next slide please. So with regard to eligibility and access requirements.

Next slide work requirements HR1 requires states to condition Medi Cal eligibility on compliance with work requirements, also referred to as community engagement requirements, for adults ages 19 through 64 with certain exemptions. Implementation is set to begin January 12027.

At minimum, states must verify compliance with the work requirements both at the application and renewal, requiring individuals to demonstrate completion of 80 hours of qualifying activities for at least one month in the six month period and these activities can include work, work, work program, community service, at least half time, enrollment in an educational program, or a combination of these activities.

Alternatively, an individual may satisfy the work requirement by having an income of at least $580 per month, the federal minimum wage multiplied by 80 hours. The law requires states to exempt certain groups and permits exemptions for those experiencing a short term hardship.

We estimate the impact to California to be up to 3 million Medi Cal Members who may lose coverage as a result of this and a loss of over 20 billion in federal funding as a result of these new requirements. This would significantly drive up our uninsured rate and raise costs for hospitals treating uninsured patients. Next slide please.

The next item is a semi annual redetermination process and this is effective January 1, 2027. States be required to redetermine eligibility for adults enrolled in the Affordable Care Act optional Medicaid Expansion Coverage group and this would be again redetermination every six months.

As a reminder, the ACA Medicaid Expansion Eligibility Group encompasses adults ages 19 to 65 who qualify based on income so under 138% of the federal poverty level.

It includes individuals with varying health needs such as those with chronic conditions, including substance use disorders and mental health conditions, low income workers without access to affordable employer sponsored coverage, parents with incomes too high for pre ACA Medicaid Parent Eligibility Group and other individuals.

Currently, states may redetermine eligibility for this group no more frequently than once per year as provided under this it is now turning to twice per year so thereby kind of really requiring more paperwork, more churning through the process like work requirements.

This change, as I mentioned, is expected to increase churn for the AC expansion population as individuals cycle in and out of the program with greater frequency, creating a risk of disruptions of care.

More frequent redeterminations will result in earlier terminations for some individuals who who experience an increase in income but are also likely to result in so called what we call our procedural terminations like work requirements. The change will significantly increase state's administrative workloads and associated costs.

We estimate about 400,000 individuals may lose coverage as a result of this provision. Next slide please. Retroactive Coverage Currently, when an individual enrolls in Medi Cal, the state must provide retroactive coverage for the three months preceding the individual's Medi Cal application.

Under this provision, effective January 1, 2027 retroactive coverage will be shortened from three months to one month for the ACA expansion adults and two months for all other Medi Cal applicants. We estimate about 86,000 individuals may be impacted by this population policy. And then finally, in the eligibility and access space. Next slide please.

Cost Sharing Cost sharing for the ACA Medicaid Expansion adult population will begin October 1, 2028. This provision requires States to impose cost sharing for services provided to ACA Expansion adults with incomes above 100% of the federal poverty level. Next slide please. Now moving on to HR1.

Significant restrictions on state funding tools and vital funding mechanisms that are essential to keeping our hospitals, nursing homes, physicians and other healthcare safety net providers stable. These provisions may be particularly devastating to many rural and critical access hospitals that are already financially restrained. Next slide please.

Provider tax limitations HR1 does a few things related to provider taxes, such as our managed care organization tax and our hospital quality assurance fee. First, effective immediately, it establishes a moratorium on future or increased provider taxes.

All states except for Alaska use provider taxes to Fund the non federal share of their Medicaid programs, a practice dating back to the 1980s. This provision freezes taxes and bans new ones threatening this vital funding stream. Second, provider taxes are generally required to be broad based and uniform, meaning that they apply equally to all providers.

Prior to HR1, states were entitled to waivers to demonstrate to waive these requirements the broad based and uniformity requirements if they demonstrated to CMS through a statistical test outlined in federal Medicaid law regulations, meaning that it does not shift the burden of the MCO to Medicaid providers. Shift the burden of the tax Excuse me.

As enacted, this provision prohibits any tax any provider tax that either imposes a lower tax rate on providers explicitly defined based on their lower Medicaid volumes compared to those with higher Medicaid volumes or taxes. Medicaid units of services at higher rate than non Medicaid units of services.

The effective date of this component is the date of enactment of HR1, unless the Federal Department of Health and Human Services Secretary allows for a transition period of three years.

Finally, for ACA expansion states such as California HR1 reduces the existing 6% cap on provider taxes by 0.5 percentage points per year beginning October 2020 until the cap reaches 3.5% in 2032.

Provider taxes are essential to keeping hospitals, nursing homes and other providers stable, as I've mentioned, and this cut may be really particularly critical to and vital to our healthcare delivery system. Next slide please. Another important tool states have to finance the Medicaid program are state directed payments.

HR1 limits how much federal funding hospitals can receive through certain types of payments. This means less funding for both public and private hospitals. In California, states are permitted to direct managed care plans on what amounts to pay providers so long as they meet certain requirements set out in rule and receive approval from CMS.

Prior to HR1, these state directed payments may be set up to the average commercial rate. HR1 now limits the scope of any new state directed payments to 100% of Medicare.

For ACA expansion, states like California states with existing state directed payments above the Medicare rates will need to reduce our state directed payments by 10 percentage points beginning in 2028 until the state directed payments are no greater than 100% of Medicare.

These financing tools are critical to support our safety net and critical access providers and so really constrains the ability for us to raise Non Federal Share Dollars to be used to match to pay for our providers in the medi Cal System. Next slide please.

The Rural Health Transformation Fund One of the mitigation strategies included in HR1 is the establishment of a $50 billion Fund for rural health care providers. Half of the funding will be allocated equally across states with approved applications, and the CMS administrator will have discretion over distributing the remaining 50%.

A broad range of health care providers will qualify for funding, including rural hospitals, rural health centers, federally qualified health centers, and community mental health centers. Community mental health Centers. The Department of Healthcare Access and Information will be administering this program for the state. Next slide please.

And the final provision related to state financing is a change in federal funding repayment penalties. The law makes significant changes to the Payment error rate measurement or perm program in Medicaid. Effective October 1, 2029 HR1 removes the federal good faith waivers for flexibility for reducing payments for administrative payment errors.

The law essentially eliminates CMS's authority to waive financial penalties even if the state is making a good faith effort to address these errors. Next slide, please. The next area that we will cover is the immigrant coverage limitations. Next slide please.

A Reduction in FMAP for Emergency Medical under this provision beginning October 12026 HR1 prohibits states from receiving 90% enhanced federal matching rate for emergency services provided to individuals who, but for their immigration status would have qualified under the ACA Medicaid expansion group.

And as a reminder, we get 9010 matching rate from the Federal Government for this population. Instead, states will receive their regular FMAP, which is 5050 for all emergency Medicaid services. So significant reduction in federal dollars for these services. Next slide please.

This is also compounded with this change to changes on the restriction of lawful immigrant eligibility for MEDI Cal. HR1 restricts who is eligible for full for satisfactory immigration status funding. Under current law, states are authorized and sometimes required to provide coverage to various groups of lawfully residing immigrants.

Beginning October 1, 2026 federal Medicaid and CHIP funding will no longer be available for full benefit coverage for most refugees, asylees, victims of human trafficking, certain individuals who deportation is being withheld or who are granted conditional entry, or individuals who have received humanitarian parole. States will be permitted to provide coverage to these groups using their own funding.

And finally, next slide please. Next slide. The one year ban on federal funding for prohibited entities that provide abortion services for one year period following HR1. This provision was effective upon enactment of HR1. This provision bars Medicaid participation by certain prohibited entities or providers, including Planned Parenthood, that offer abortion services.

That is, Federal Medicaid funding cannot go to nonprofit providers that offer abortion services even if those services are limited and legally permitted and even if the provider also delivers essential services such as preventive care like cancer screenings, contraception and STI testing. This funding ban applies to any and all Medicaid services offered by such entities.

In California, roughly 80% of Planned Parenthood patients rely on Medi Cal, meaning this proposal would effectively strip about 300 million in federal funding for one of the state's largest providers of reproductive health care.

At the end of July, two preliminary injunctions were issued that blocks the the Trump Administration from implementing this provision for certain for the providers under those preliminary injunctions. That concludes my presentation and happy to answer any questions.

We'll move on to the next panelists and then move into questions.

Thank you. Good afternoon. Angela Pontes, Senior Vice President of Government affairs for Planned Parenthood Affiliates of California, representing the seven Planned Parenthood affiliates in the state operating 109 community health centers. I want to start by thanking the committees for hosting this, convening this hearing and providing a platform to discuss the impacts of HR1.

This sweeping Bill now law contains many provisions that will significantly impact access to essential health care services in California. For Planned Parenthood, the impacts of HR1 were immediate and devastating. As the Director mentioned, this law federally defunded Planned Parenthood overnight.

Congress did this by cutting off federal funding to pay for any services in Medicaid provided by a prohibited entity, which was defined as a nonprofit organization that primarily engages in reproductive health care, provides abortion, and received more than $800,000 in state and federal Medicaid funding in 2023. This nearly exclusively applies to Planned Parenthood health centers in California.

The seven Planned Parenthood affiliates serve one third of all Planned Parenthood patients nationwide. They are collectively the largest provider in the Family Pact program and the largest provider of abortion and Medi Cal. It's about 25,000 patients per week.

As the Director said, over 80% of our 1 million patient visits that they provide annually are reimbursed by the Medi Cal program. In fact, one in four Californians has received care at a Planned Parenthood. Everyone has a Planned Parenthood story. This is why defunding Planned Parenthood is devastating.

The rest of the state's medical provider network cannot meet the demand for sexual and reproductive health care in the state. Without Planned Parenthood, HR1 is catastrophic to California's ability to access health care. As it stands today, there is a preliminary injunction blocking the implementation of the defund. However, this has already been appealed.

The current federal Administration has made it clear that eliminating Planned Parenthood and therefore access to abortion and reproductive health care is a priority that they will not walk away from. We know that relying on litigation is precarious and unstable.

It is likely that the U.S. Supreme Court could be asked by the current Administration to overturn the injunction in a matter of weeks. This means that without state intervention, Planned Parenthood health centers will stop getting paid for serving Medi Cal patients. If that happens, a full Planned Parenthood defund.

The seven California Planned Parenthood affiliates anticipate that they will need to close health centers, drastically cut their hours and days of operation, reduce their workforce and or scale back the services that they provide. Patients who rely on Planned Parenthood will have more difficulty accessing services, including family planning, screening and treatment for STIs and cancer screenings.

In terms of dollars, the state receives about 305 million in federal matching funds annually to reimburse Planned Parenthood for the family planning services they provide. And this is a good time for a reminder that no federal funds can be used to reimburse abortion services.

If the defund provision is reinstated, the Medi Cal program will face a shortfall as a result of lost federal funding and the Medi Cal system risks losing the state's key provider of sexual and reproductive health care.

We look forward to continue working with the Legislature and state leadership to ensure that patients continue to have access to Planned Parenthood health centers and protect California's constitutional right to reproductive freedom. Thank you so much.

HI Adam Dorsey, California Hospital Association we represent about 400 hospitals across the state. So HR1 really cuts at the heart of financing for health care systems across the country and especially here in California, it attacks the way to raise revenue to pay for providers.

It goes after the payments themselves and it goes after eligibility and coverage for beneficiaries. States, unlike the Federal Government, states have to balance a budget every year and state governments have to pay for a number of things. You got to pay for schools, you got to pay for roads, you got to pay for parks.

And in California, the medical program is one of the largest health care programs in the country. And so this Federal Government back in the 1990s created a regulatory framework for healthcare related taxes to help finance Medicaid programs across the country. Because for many, many decades, Medicaid programs everywhere have not been known as really good payers for providers.

And in order to maintain adequate access to Services, Section 1903, the Social Security act was amended to allow for these kinds of financing arrangements and the state started implementing these in the early 2000s following the.com bust and in 2009 implemented the hospital quality assurance fee in California following the great financial crisis and in the 1213 fiscal year, we eliminated the California Medical Assistance Commission, which set per diem rates and used General Fund to pay rate increases for hospitals.

And so these frameworks, what they've allowed providers to do is to self finance the rate increases in order to maintain that access to care. And so what HR1 does is it ratchets down the ability for providers to continue to self finance those, those rate increases and put up the non federal share.

So as Director Baass laid out, you've got the reductions on the tax side. They're going to start ratcheting down the amount of tax that can be raised starting in 2028 by half a percent a year. And it reduces the total size of these programs from 6% of total net patient revenue down to 3.5%.

So that's on the revenue generation side. On the provider payment side, it ratchets down payments until they hit Medicare levels. So currently in California, hospitals receive about 80 cents of every dollar that it costs to care for a medi Cal beneficiary. And certainly that number will kind of creep back down as you get to Medicare levels.

There are some services depending on the hospital type and the service delivered. Some services are paid over Medicare rates, some services are paid under. But when you ratchet that down and make it a ceiling for all services, then you really are reducing the amount of money going to providers and reducing access.

We estimate that HR1 will result in between 66 billion and $128 billion loss in revenue to hospitals over a 10 year period. That's between 14 and 30% of total hospital medi Cal revenue. So that's a tremendous, you know, risk for the system and for access in the Medi Cal program.

The other, of course, huge problem that Director Baass, you know, went through as well is the direct access to coverage in the program with redeterminations with cost sharing and some of the other provisions. These are really, really damaging to beneficiaries that hospitals care for and will continue to show up in the emergency room.

And, and they will continue to jeopardize the ability of hospitals to keep their doors open because these beneficiaries will continue to show up at the emergency room even after they have lost coverage. Unfortunately, the other sort of elephant in the room is that the state budget is your vehicle for addressing a lot of these problems.

We know that there is a structural deficit in the state and we stand by to continue to work with you all to try and determine how we can help come up with ideas that stabilize the healthcare system.

Stabilize access for Medi Cal beneficiaries while understanding that you all have other problems that you're trying to solve as well and look forward to answering any questions.

Good afternoon, Linda Nguy with the Western Center on Law and Poverty. Thanks for the opportunity to speak and hosting this informational hearing. The Affordable Care Act, specifically the expansion of Medi Cal coverage to adults without dependent children, expanded comprehensive health coverage for over 5 million Californians.

Coupled with other reforms and the establishment of Covered California, the state slashed the uninsured in California from nearly 18% in 2013 to about 6 to 7% following the act.

Although HR1 does not repeal the ACA, it threatens to roll back these coverage gains for low income Californians, threatening to return California to double digit uninsured rates, significant medical debt and worse health outcomes. Studies show that Medi Cal expansion resulted in reduced disparities across race, ethnicity, income and education levels and decreased mortality overall and for certain conditions.

In other words, Medi Cal coverage is life changing and life saving. HR1 targets those who gain the most under Medi Cal the working poor and adults experiencing homelessness. Prior to Medi Cal expansion, only seniors, people with disabilities, very low income children and their parents or guardians were eligible for Medi California.

Harkening back to the idea that only people who could not be blamed for their poverty were deserving of health care, Medi Cal expansion recognized that healthy people means healthy communities and that low income people should not be forced to make decisions on whether to get medically necessary treatment, incur medical debt or go without care.

In fact, studies show that Medi Cal expansion is linked to reductions in poverty rates, food insecurity and evictions. Based on other states experience, we know that work requirements do not result in more people working, but rather significant coverage losses.

Over 60% of adults on Medi Cal are working and an additional 20% are unable to work due to illness, disability or caregiving responsibilities. People on Medi Cal already have a duty to report any change in circumstance that might impact their eligibility, such as change in income, family size or address within 10 days.

More frequent redetermination and work requirements create administrative red tape that could result in millions losing their health coverage. An increasing churn which refers to people cycling on and off of Medi Cal within a short period. The ACA significantly reduced churn by simplifying the eligibility process while HR1 adds additional paperwork.

People experiencing homelessness will be disproportionately impacted from these administrative hurdles not because they are ineligible, but because of the inability to comply with more onerous paperwork requirements or challenges maintaining employment while lacking stable housing. At least 75% of the total population experiencing homelessness is covered by Medi Cal.

We expect this number to drop and create greater strains on hospitals and healthcare systems systems. However, California can and should take innovative and bold approaches to protect residents from these federal cutbacks.

A renewed commitment to improving systems like during the original ACA implementation and CALAIM implementation will be needed to maximize automation that keeps Medi Cal active while being mindful of AI pitfalls, bringing Member centric efficiencies in today's currently burdensome manual processes and centering Members in implementation so that there's effective, fully translated, understandable communication and outreach.

We appreciate the Legislature and Administration are engaging with stakeholders on HR implementation which unfortunately will result in healthcare coverage loss. This highlights the need to explore all options including those that I mentioned, as well as new non regressive revenue solutions. Thank you.

Thank you to the four of you. I'd like to kick it over to my Committee Members to start any questions. Assembly Member .

Thank you Madam Chair for direct Dr. Baass, you had a slide that said that there would be restrictions on lawful immigrant eligibility for Medi Cal.

I assume those are going to be for those that have work permit or are even permanent residents and are those restrictions anticipated to be for chronic diseases or what type of restrictions you think are going to be existing?

So the restrictions that I mentioned are restrictions in changes for how much the Federal Government covers for individuals. So today for example refugees, we get full scope coverage from the Federal Government meaning that they pay 5050 with us.

The change under HR1 is shifting those individuals to really unsatisfactory immigration status where the state needs to pick up the full cost of those non emergency services. So those changes really result in a kind of a state General Fund pressure as a result of a change in a loss of federal dollars.

So the restrictions, the restrictions are on monetary on correct. Not necessarily on the care that they need. If it's a chronic disease, it's a.

Change in the federal funding eligibility requirements in terms of covering full scope versus just emergency services.

Thank you for clarifying that. Thank you.

But because it's monetary restriction, there's a potential that it could lead to service restrictions.

All of these changes are. There's just definitely state budget pressures regarding, you know, the loss in tens of billions of dollars and you know, what, what, what actions we will need to take.

See no other questions from colleagues.

I have a couple questions.Thank you Madam Chairs. Nice to see all of you. Is it possible to get a copy of the presentations of all the presenters?

We have the one from the Hospital Association, but given the statistics, they're very important in information we can use when we're out and about to educate people of what's happening. Thank you.

Assembly Member.

Well, this is concerning. So I appreciate all of the information today. You know, we knew that this was coming, being both on Assembly Health and on the Health Budget Sub with our Chair, sitting next to me. And you know, the... It's difficult to think about the impact that this is going to have honestly.

And so, you know, the... But I wanted to go back to the testimony of Mr. Dorsey just to make sure I had the numbers correct that you said. And you said that with the change to the tax it would mean how much in possible lost revenue?

We think it could be between 66 and $128 billion over a 10 year period. The range is really dependent on how the federal government interprets the the federal law as passed by Congress, signed by the President.

And there's a certain amount of administrative flexibility involved in all of that in terms of whether they approve programs that are currently pending and that sort of thing. And so it's a wide range, but it's really serious regardless, whether you're talking about the low end or the high end.

Right. So I was visited today by hospital, not in my district, but that I've been working with Ridgecrest Hospital because I chair Military and Veteran Affairs. And Ridgecrest is next to a China Lake Navy Facility. And it's this unique situation where it's really out in the middle of the Mojave Desert. There's not another hospital for 100 miles.

They are really essential to the function of that naval base which does really specialized national security work. They have incredibly brilliant scientists who create rocket fuels themselves and, you know, and all kinds of other things. And they have been financially struggling, unfortunately.

You know, the federal government has helped them out here and there, but they're not right now talking about helping them out. And they had to close their labor and delivery unit. They were able to get additional funding to reopen that and now they're facing possible closure of that again.

We know that especially in our rural communities that, you know, this funding is so critical to sustain hospitals which disproportionately and in low income communities that really rely on these Medi-Cal dollars. And so, you know, there's a lot of rhetoric going around about why California needs to fight back right now. And just that one reason.

We had presentations from four people about many, many things that were included in HR 1 that are going to be removing, limiting, taking away health care from millions of Californians. And just that one reason will lead to hospital closures. And so, you know, it's certainly sobering to hear the real impact of what this is going to be. We knew it was going to be really bad. It's horrific.

And I think it's going to be critical that we get very creative here in California and continue to be as resourceful as we can and continue to fight in every way that we can to keep all of the dollars that California deserves. Those $80 billion that we pay in taxes that should be coming back to California, that we have to continue to fight every opportunity that we have to make sure that we are protecting California in every way we can. So thank you for all that you do. Thank you for the presentation and the information today, and we'll continue to work together.

Thank you. Thank you, Madam Chairs, and thank you to each of our presenters. I know how hard you've been working on this. We held in the Health Budget Sub, I think we had at least five hearings on the full budget, 11 hearings.

And at almost every single one of these, we talked about cuts to the Medi-Cal program, cuts to the Medicaid program, the detrimental nature of HR 1. And you may have covered this at the top of your testimony, so please excuse me if I'm asking you to repeat.

But a lot of our focus, a lot of the conversation has been about how the cuts will affect individuals who have insurance now or who have health coverage now. The 94, we have 94% of Californians who are covered now.

We expect a huge decrease. 15 million Californians, we expect at least 2 million, if not more, to lose their healthcare coverage. But could you just put some color, some contour of what that means for the rest of California when you have 2 million people that lose health coverage. What kind of pressures does that put on the rest of the system that other people across California are going to feel?

Some of whom really believe that certain people just don't deserve health care, but others of whom believe that a cost saving measure at any cost is a good cost saving measure and don't really understand the adjunct effects of cutting care and how that will affect the system as a whole. And if you could just speak to that briefly would be helpful. And whoever and maybe each of you have different lanes on this, and I'd be happy to hear from each of you.

I'm happy to start. Well, I kind of talk about the Medi-Cal program. I think these cuts and these changes are broader than just Medi-Cal. If you think about the healthcare industry losing tens of billions of dollars, just the healthcare industry in general, that means closures.

That means changes to where people get their care, and not just people on Medi-Cal. It is individuals wanting to go to an emergency department that is no longer there because, you know, they may not have the funding to do so. And another topic that we haven't really talked about is workforce.

All of the jobs that will be lost as a result of the closures or the reductions in services is a potential. I mean, these are potentials. But because of the billions of dollars in funding being swept out of our health care delivery system, it is broader than the Medi-Cal program. It's broader than Covered California. It is. It is a sector wide issue.

I couldn't agree more. I was reminded by a hospital in a rural area today, they are by far the biggest employer in their town. Some of these hospitals are already really on the brink. And our boss very helpfully reminds us that, you know, there's not a door when you walk in the emergency room for a Medi-Cal beneficiary and a commercial coverage beneficiary. If the hospital closes, the hospital closes for everybody. So, yeah, I just couldn't agree more that the impacts of this are unfortunately going to be widespread.

Maybe just to follow up, not to put Planned Parenthood on the spot. But we already had one closure, maybe already talked about it, in Santa Cruz County. They said that due to cuts, they were losing $7 million a month. And so the clinic is closed. It's not going to reopen. What kind of impact does that have on the rest of the system when it comes to family planning and reproductive care?

Yeah, thank you for that question. So one of the Planned Parenthood Affiliates did have to make the difficult decision to close five health centers already since the July 4th signing of this bill. So that is, you know, like I said in my testimony, the Medi-Cal system cannot fully absorb the reproductive and abortion health care needs that Planned Parenthood provides if Planned Parenthood were to no longer exist in the state.

But the neighboring health centers, depending on where those locations are, do have to open up their doors to take on these patients. Like I said, 25,000 per week in Planned Parenthood. It's about 22,000, I believe, of those five. So they will need to be absorbed by other health centers. And I do want to agree with my colleagues up here as well that we are talking about jobs, we are talking about patients. And for our health centers, once those are closed, they are not reopening.

Assembly Member, and then we'll turn to the Senator.

Thank you for providing all of your testimony and detailed information. I have a very specific question on the eligibility requirements and having to reauthorize eligibility for people. From my understanding, HR 1 puts a huge administrative burden on the system here in California. Do we have cost estimates of what that would look like?

We don't yet. That is something that we're working through right now.

Okay, thank you. I would love to get follow up on that when you have it just because we're trying to see where that cost shift is going to go. Because at some point in some way we are, Californians are going to bear the cost of making sure that people in California continue to receive high quality care. Thank you for the work that you're doing and keeping us informed.

Senator.

Thank you, Chairs. Thank you so much for having this joint hearing. Want to thank our first panel for coming and speaking with us today and kind of giving us an initial kind of outlay of the landscape. Just have a couple of questions. I'll start I guess by piggybacking on the Assembly Member's question around eligibility. So have you all thought about how patients will be notified if they are no longer eligible and how you are also going to be notifying providers and hospitals?

You know, one of the things that is very challenging for providers and hospitals and also patients is thinking that they have insurance and then showing up to clinic or, you know, the day of a procedure and realizing that something has lapsed. So do you have some kind of process currently, which I know is a little flawed from what people have told me, but also just from my own experience, or have you thought about how you're going to do this?

So that is something that we're thinking through right now. So for these eligibility changes, they mostly go into effect January 1, 2027. So so as part of our planning for getting ready, whether it's the county eligibility systems, the county eligibility worker training, provider engagement, those are all things that we're planning for right now to kind of set up a process by which we can be have a good robust communication protocol and tools to help us make sure individuals understand what the changes are, where they're going.

I will say this is the first time, given some of the state budget changes, we actually came out with communications really focused on our members and community based organizations that work with our members outlining our budget, our state budget changes that we just adopted.

Really trying to focus our comms and our outreach really strategically to touch individuals who are there who can support our members. I will also highlight we have our coverage ambassadors, which was an initiative we launched as part of the public health emergency unwinding.

We have over 8,000 individuals who have signed up as our coverage ambassadors. And we are developing toolkits, we're developing messaging using those trusted community partners as a way to do this outreach to our members. But we're at the very beginning stages to think about some of these steps.

Okay, thank you. And with the one year ban on federal funding for programs like Planned Parenthood, what is the... First of all, is that from January 4, I guess, 2025 to January 4, 2026? Is that the thought process?

Yeah, that's how we're treating it. It was went into effect immediately. So that was, you know, July 4th signed and then into July of next year. So pretty much on the fiscal year.

Okay. And with these injunctions, it wouldn't push anything back, right?

No.

Okay. And is, has there been any discussion about what happens after January 4, 2026?

I think, you know, we cannot say whether that policy will or will not be extended. And I don't think we're taking for granted that it will go either direction. We are at this time trying to plan to continue operations, you know, even on a day to day basis with the volatility of the litigation and the implementation of the policy. And quickly the lights can and cannot go off. So we are not planning on it being extended or not being extended either way. I think that that really can be up in the air.

But you haven't heard anything from like your federal counterparts or the people who are in DC about whether or not there's been any conversation about what is going to happen after July 4, 2026?

We are, you know, of course, tracking it. I think that the federal administration and the current Congress has made it very clear that defunding Planned Parenthood is a priority of theirs and that should they be able to, they would.

The bill as introduced was a 10 year Planned Parenthood defunding and it was amended to one year in the second house in the Senate. So moving from the Senate. So that was part of the, you know, changes to move that policy through the Congress and pass it. So given that it was initially 10 years, I don't have confidence that they would not extend it if able to.

Thank you for that. Really concerned about the prohibition around the MCO tax. We have had multiple conversations for many, many, many years about Medicaid reimbursement rates, the need to increase our Medicaid reimbursement rates and utilization of the MCO tax for something like that.

So have you all started thinking about how we are going to be able to incentivize providers to even see Medi-Cal patients, considering the fact that financially they have said it's just oftentimes not fiscally possible or financially possible?

So we're currently going through HR 1 and MCO provisions or the provider tax provisions and the potential federal rule related to provider taxes and trying to assess, you know, the modeling for this, what the kind of the new framework could look like. But we have not kind of thought about how else to incentivize our providers to participate in the Medi-Cal program.

Interesting. Okay, and my last question. So with these potential new cost sharing requirements, how exactly is that going to... Have you thought about how that's going to work? Like, how would someone who's coming up, who's on Medi-Cal know that they've got to pay $35 based on what they made this year and next year maybe they pay 25. Have you thought about how that is going to work?

That provision does not go into effect until October 1, 2028. So right now in the eligibility space, we are definitely more focused on the work requirements and the semi-annual redeterminations, which go into effect almost two years earlier. And so those are things that we will have to work through as we plan for cost sharing.

Thank you.

Thank you so much. I'll start with questions with you, Director, on the worker requirement. What options do we have or what options are available for us to delay the start of the implementation?

So there is the opportunity, and we don't have the details on this process, for states to request a delay for up to two years. So through December 31, 2028 instead of having it effective January 1, 2027, as long as the state is making a good faith effort. So we don't have any more details on that process, but that is part of HR 1.

Right now we're kind of planning to implement, but we'll be also exploring that option. The federal government, the HR 1 requires the actual guidance from CMS to be available June 2026. So we still have months away from when we would expect federal guidance on how to implement this. So lots of just, you know, lots of uncertainty, I would guess I would say.

Do we expect all federal regulation guidance to come down on that date?

That is one of the... There's only a few provisions where there's a specific date that HR 1 provides, and that is one of them for the work requirements.

As we're looking at collecting this worker requirement data, are we looking to do this at a county level or are we going to do statewide platform to collect this info?

So currently this is done at the kind of the county eligibility systems and also, you know, we are working closely with the Department of Social Services as they think about their CalFresh requirements and CalWORKs requirements in this space to really think about how do we automate as much as possible, how do we take advantage of when the client is before the county eligibility worker. And so really trying to plan for an integrated, seamless, really automated process in this space.

Are we thinking about possibly taking advantage of the ability to collect this extra data to look at it statewide just to have more... You know, as we're have, we've had these conversations we always turn to like we don't have this data at the state level, it's at the county level and it's really hard for us to collect this, all this information. Are there conversations or thoughts around making this more accessible for statewide policy down the line to be able to turn to this data?

In terms of the collection of... So some of this information we rely on other EDD or we could rely on some of the other entities. We're also exploring partnerships with UC and higher ed on if we can, they can meet community engagement requirements by accessing that data and seeing if that's available. So we're thinking through all different ways to do this. But I will say that kind of that county eligibility and the CalHEERS and CalSAWS systems are county run, county kind of based rules engines.

Okay. I'd like to continue, I think we'd be interested in that statewide just to leverage some of those partners you just mentioned, like EDD. On the redetermination, you mentioned some of the exceptions to that. Is the IDD population exempted from the biannual now redetermination? For the redetermination now every six months, is the IDD population exempted from that?

If they are part of the Affordable Care Act Medicaid expansion population, they are not exempt. And so it depends on the category, their aid code category. And so I can't answer that explicitly, but it really does depend on aid code.

Okay. And then going back to the MCO conversation, the new policies or guidance, does that impact our current MCO tax or the future ones?

So this is where there's a bit of, I wouldn't say uncertainty. But our current MCO tax framework is, does not meet the requirements in HR 1. But it does provide, HR 1 does provide for a three year transition period approved by the federal HHS secretary. So we will apply for that transition period.

We check regularly with CMS on what's the criteria, what will the process be for that. They don't have any details or process to kind of relate to us on that. But so there is a bit of uncertainty in terms of our current MCO tax and whether or not it will be go through the end of 2026 as approved today.

Got it. As it correlates to our state budget in January around the corner with our new the Governor putting out his budget proposal. It's just gonna be a lot of uncertainty then because we just... So we'll go through another crazy May Revision next year.

I mean ideally we will know about the transition period prior to Governor's Budget and we will have requested it and, you know, knock on wood. But that our goal is to continue the existing MCO through the approved period.

Okay. And then on the Rural Health Transformation Fund, I know we're going to be... You put in your slide, you're going to be submitting an application for those funds. $50 billion total. How much are we going to be asking for?

We do not know at this point. The Department of Healthcare Access and Information, or HCAI, will be administering this fund. And I know that there are conversations with CMS that are planned in the coming weeks to get more details on this.

Do we know, because I know in the past we've had some funds like this similar. Do we know if this is going to supplement or supplant the current funding we have for rural hospitals? Or maybe it's an HCAI question.

Yeah, the distressed hospital loan was state dollars. These are new federal dollars. I don't believe there are existing federal dollars for this particular purpose today. But yeah, I would definitely defer to my colleagues at HCAI.

And then Director, last question for you. What platform exists or are we working on platform to collect co-payments since that's going to start in a couple years?

We don't have a platform today. That is something. Again it starts October 2028 and so we will be working towards implementing that in the coming months. But again, work requirements in the semi-annual redeterminations are effective January 2027. So just a bit sooner. And so that's kind of the focus right now for planning.

Okay, thank you. Angela, you mentioned you know state intervention is needed. You gave out a number of a 305 million in federal fund. What does state earned prevention look like?

I mean I think it is in the form of funding. Currently, we have the injunction. If the injunction is overturned and Planned Parenthood is defunded, it really turns to working with the Department for how those claims can be submitted, if those claims can be submitted, and how those claims can be reimbursed.

I think many of you are aware that a lot of the Planned Parenthood services, the family planning and STI service, testing services, are an enhanced federal match, which is a 90% federal and a 10% state funding match. So when Planned Parenthood is federally defunded, Planned Parenthood is not receiving a 10% claim reimbursement for services that have been provided.

Planned Parenthood is not receiving reimbursement at all without those dollars. So it's going to look like working with the Legislature and the administration to identify a means for those dollars to be paid out for the claims. And it will have to look like state only dollars.

I mean, is there a scenario where we create... I mean, are we looking at it? I know it's all dependent on the dollars. Right. A state program to fund these kind of reproductive health, gender affirming care, health insurance for the UIS population.

I think these are all options that are part of the discussion. We've been working very closely with Planned Parenthood. Just the ups and downs of the weeks of it's defunded. We have an injunction. So really trying to think through options to ensure services are still available.

Thank you. And Adam, you gave us some numbers. What does that revenue loss translate to in your hospitals?

We think it's about 14 to 30% of total Medi-Cal revenue.

Let me rephrase my question. I got those numbers. What does, for service, what does that actually translate to? What does that look like?

Unfortunately for some hospitals, it's probably too large of a gap for some hospitals to remain open. Should all of these cuts be effectuated the way that they're currently anticipated without radical changes in some other factors that I think that we're all still going to have to collectively think through. And I appreciate this conversation because I think that this is a step in that direction and trying to figure out how to proceed forward in a world where there's less dollars.

In a world where there's less dollars, how do we get the allotted dollars to CHA, or I mean not CHA. To the hospitals, to your members. How do we streamline or make it easier for you to get the dollars that you are able to get during this time? Is CHA thinking about regulations, anything that we can streamline to protect the dollars that we do have?

Yeah, you've hit the nail on the head. I think that... So self financing has been really important because it's been a way to benefit the access to the services that are needed without putting undue pressure on the state General Fund and, you know, and allows for a more sustainable system.

So we need to look at ways in which that system can be improved to fit within the current federal regulatory structure. The other thing that we have to do is we have to think about healthcare delivery and are there ways that we can look at operations to be as efficient as humanly possible.

And then the other thing that we're going to have to look at, and this is kind of a larger collective conversation. It's going to be a multi-year conversation is around are there rules in the state that are good ideas and solve certain problems but we can't afford right now if we want to have, you know, hospitals remain open? Is there regulatory relief? Are there things that we can do on that front that allow hospitals to keep their doors open while we're getting through this difficult period?

Thank you. And Linda, my last question to you, and I'll turn over to my Co-Chair here. How do we make sure that our consumers don't lose Medi-Cal or access to health insurance or access to health?

Great question. These are massive changes. I liken it to ACA implementation where that took years of planning. And so do appreciate that the Department is engaging us early. We know that decisions are being made as we speak for because these system changes will take time.

But we also know from past experience, lessons learned from unwinding that there will be challenges that... Counties had difficulties going through unwinding for and so to have to do twice the number of redeterminations, check on work requirements. These are massive undertakings.

And so making sure that the systems are ready but also that the communication happens, the outreach happens to the community, but that communities can speak to the counties. From some of the lessons learned. That there I think to your question of the systems in place. We know that people tried to reach out through CalHEERS, BenefitsCal.

These are statewide systems that had challenges there. And so making sure that we're as prepared as possible, but do expect that regardless of the preparation unfortunately that there will be coverage losses.

No need for an answer here. I just leave with a thought for you and all the other advocate groups. I don't remember what pre-ACA looked like or I just don't remember. So I'm trying to think what programs existed at that time to try to close the gap when we had double digits or percentage in uninsured population in California.

Are we looking at that to bring those back that are that can help cover this gap. But just would love to continue with advocates on that conversation of what we did then to try to close that gap that maybe we can look at now. Madam Chair.

Thank you, and thanks so much for this incredibly informative panel. One of the things that I think we need to make sure that we're doing right now is to, one, just kind of push back on some of the assumptions that are built into HR 1 in terms of the impact on our overall healthcare.

And the other is for us to be able to kind of roll up our sleeves and immediately get to work in terms of the harm mitigation efforts that we are going to need to engage in to be able to ensure that we don't have the kind of loss in healthcare coverage that we know is going to exist.

So part of my questions, several of my questions will revolve around that. The first is with the work requirements and particularly the eligibility checks that are built into HR 1. There have been other states I know, and hopefully you can share, that have done this already. Georgia, for instance, around work requirements.

Do you all have a sense of the precipitousness of the impact or the kind of the immediate impact of, from a timing perspective of the number of people who are kind of fell off of healthcare or kind of off of the cliff? If you took Georgia, for instance, that had work requirements.

I'll jump in here. We've heard that there was 77, up to 77% procedural terminations for these states that did it through a manual process. And so that is a shockingly high number of people who are being terminated just for paperwork reasons, not necessarily because they're not working. As shared earlier, many of the people on Medi-Cal Medicaid are working.

And so we so these are really administrative burdens. And so I think automating it will help reduce that. Automating the exemptions, everything, the different pieces of it. But that takes a lot of time, and especially when you think of how old some of these systems are. I think the planning has to happen now.

I think Senator Weber will attest and even the Chair from Budgets of Health, our conversations and our IT programs. Right, Director? We are not good with our IT programs here. So you're right.

We've been involved in some conversations with our colleagues in Georgia, Tennessee, and Arkansas. And just kind of reiterating, I think that some of the complications that have been faced in all of those states when either standing up or even attempting to stand up some of these programs have not been easy. And so apologize to Director Baass for having to be faced with implementing this and, you know, stand ready to help in any way that we can.

And I think the, directed towards Director Baass. So the idea of the work requirements, eligibility checks, the what we've just established is going to be an incredibly heavy lift in terms of making sure that we can do that.

We do have in the State of California with our last budget in place some... Well, not a component of those pieces. What is the interplay between our need to be compliant with these new eligibility systems and what it will take for us and the federal funding repayment penalty structure?

So is there a chance where California will not, being the largest provider of Medi-Cal services or Medicaid services, will basically be in a position where we have not been able to stand up the systems that will require us to do this? We will have different issues with not being able to systematize this in a manner that is effective and then being faced with these funding penalties.

Agree. The perm rate change the ability to waive the flexibilities if we were making kind of corrective action are working towards that goes into effect at the end of 2029. But the interplay of all of these changes together is something that we are thinking through.

I don't have a response for you in terms of what does X mean for Y, but we are thinking through how all of these interact and how to, again, as we've all discussed, really automate some of these process to take kind of the manual process out, to take the procedural process out of these determinations to make them as simple for not just our members, our county eligibility, our community based organizations who assist with this process.

I just want us to kind of hold how incredibly insidious and quite frankly evil these the components of HR 1 are because on the one hand we're putting forward work requirements that would lead to or different kind of eligibility requirements that would lead to 77.

You know, an example, 77% of people for Georgia losing health care coverage. And at the same time putting in a mechanism in HR 1 that is essentially a ticking time bomb in terms of our ability to be able to receive any federal funding.

So it's functional defunding of our health care system in the entirety that is at stake by the federal government. And that is a heavy weight to carry. And we have an early example of that with the actions that have been taken against Planned Parenthood in HR 1.

And wanted to just hit on Angela, Ms. Pontes. You spoke to the immediate closures that will happen with nearly probably 22,000 people a week receiving coverage needing to be absorbed by our Medi-Cal system, which is incredibly alarming.

We know that that has an impact not only on Planned Parenthood, obviously, but it also has an impact on other health clinics, our FQHCs, our community health clinics as well, who would be facing this kind of issue as well. Do you all have a sense of what kind of, again, just from a time perspective, runway we are talking about in terms of people not being able to receive basic health care?

I appreciate the question. I think it's also important to think about in terms of the health centers and what the health centers are providing. This is really what the patients are able to access and what patients are able to receive. And that's what Planned Parenthood provides.

Planned Parenthood operates in locations intentionally where it may be more difficult to access healthcare. In terms of the timeline, it's hard to say. What I can say is that these are real operational costs for staff, operations, services provided, keeping the lights on, paying rent. And I appreciated someone mentioning harm reduction.

I think for the affiliates it's really forward looking. And while we are currently under an injunction, there's no timeframe that we may or may not maintain that. And an overnight defunding federally can have significant impacts very quickly, as we've witnessed. So we can't say that any affiliate has a certain amount of funding available to be able to stay open without receiving reimbursements for any amount of time.

But I do think that the affiliates are looking for some sorts of assurances that there will be funding available and that their claims will be able to be submitted and be reimbursed looking forward as they're making decisions even today in terms of services provided, operations, and et cetera.

I appreciate that. And I'll ask essentially the same question of Adam from CHA's perspective. The kind of scenario planning that your hospital members are doing right now, given the potential impacts of HR 1, the reduction of the MCO tax, the FMAP, and all of the ways in which we know the revenue reduction is going to be pretty significant.

Are you hearing from your hospitals? I know that we are hearing a lot as well, but can you just provide some additional color on the kinds of decisions that our hospitals are looking to make and the timing in which they are seeking to have some kind of resolution to be able to implement that? You can't close hospital overnight.

Yeah. So as you can imagine, much like this conversation, I think that the mood is dour. You know, there's not a lot of optimism at the moment. There I think that what there's... What hospitals are generally doing is doing some multi year fiscal planning and planning what can operations look like with fewer dollars.

And for some hospitals, I think that a path to remaining open is really challenging. For some hospitals, you know, a path to maintaining all of the services that you currently provide is not going to be possible. And for and for others, I think it's just a question of, you know, are there other ways to, you know, do operations.

And, you know, keep everyone employed that you've got on staff, or is that all possible under kind of your long term and midterm planning when you know that there's going to be fewer dollars coming in. And frankly the same amount of patients. Because of the patients are still going to show up in those emergency rooms and you just don't have the dollars coming in the door to help pay for the care.

And I know that we are, we're already in a situation where hospitals were having to ask some version of those questions in terms of the kinds of services that they are able to keep open.

Senator Weber Pierson, I actually think all of the Members, Senator Menjivar and I as well, have been looking, and Senator Richardson actually too, have been looking very closely at, for instance, kind of labor and delivery functions and the fact that they're closing at a pretty precipitous rate right now because they tend to be challenging cost centers to provide care.

I think it would be helpful for us to move into a space where we are engaging in that scenario planning together over the course of the next several months to better understand from the hospital's perspective, healthcare facilities perspective what the map is for what we'll need to close when. It's going to have serious regional implications in terms of the level of access to care.

And I think work that we all need to do, obviously, with Director Baass and all of our agencies engaged in this work. It is also just, I want to, because it's hard not to get angry at this. This $50 billion Rural Health Transformation Fund for the nation.

California may receive some portion of that. Can you all put into context for us, either Director Baass or I think Planned Parenthood or CHA, kind of give us a sense of the operating revenue that is required to keep one rural hospital open that might be struggling right now.

That really, that depends. I had a colleague who would say, you've seen one hospital, you've seen one hospital.

Take one of the ones that are on our distressed hospital list.

Yeah, yeah. I mean, for some of those hospitals, you know, so we had a, you know, a partial closure, you know, recently down in Southern California where, you know, you're talking about, you know, very small facilities that are, you know, critical access hospitals.

They serve a very, very high proportion of public payer patients and there are no other providers for many miles around. So there just isn't like a plug and play alternative. And so there's... Yeah.

And frankly, something like labor and delivery, if you've got very, very low volume, kind of depending on where you are and fewer births in the state and some of those kind of larger dynamics, there's just all these other kind of forces that kind of go into a very local decision around what it takes to maintain services or keep a hospital open. And so those dynamics are obviously just made a lot more challenging by something like this that reduces the amount of dollars that come in.

Yep. Do you have a sense of the operating cost of one of those rural hospitals just to give us?

I don't have a great example off the top of my head, but I certainly can provide something to staff.

All right. My sense is from looking, even if you were just to look at the distressed hospitals, the list of distressed hospitals that we have, that a fractional portion of $50 billion for our rural hospitals is literally going to be a drop in the bucket for our rural hospitals.

And if I don't have the answer to your question, but one thing I would also add is the Rural Hospital Transformation Fund is really one time spread over the course of a few years. But these changes that we're talking about are ongoing changes. There is no, you know, end date to them. And so while this may be kind of a band aid for some of the short term challenges, it is not a replacement of ongoing funding.

Appreciate that. And then my last question. We obviously went through our budgeting process. We had a lot of very dynamic conversations between the Legislature and the administration around some of the proposed cuts and what ended up in the, in the budget.

One of the things that we knew was going to be an issue was the fact that we were kind of waiting on HR 1 and to see the impacts of what all would result from whatever Congress and the Trump administration ended up passing. Do you all have a sense of whether there are aspects of the budget action that basically need to be revisited because of HR 1?

I'll give you a concrete example. Maybe there might be others. We implemented a $30 a month premium for UIS individuals effective July 1, 2027. We now have this cost sharing requirement that goes into effect 2028 for all Medi-Cal recipients. There seems to be...

There's a timing misalignment potentially there. Are there other things that you think are kind of floating around in our budget that you think we should be taking a hard look at right now to make sure that there is alignment or full understanding of the impacts of HR 1?

Nothing is coming to mind. And I would say that the premium versus copay, those are different mechanisms and how you implement those may be differently as well. Those are the things that we are thinking through as part of reconciling the state budget decisions and everything that has come out of HR 1. So I don't have anything else to add.

Thank you. And I just want to thank Dr. Weber Pierson, Senator Weber Pierson for raising the issue around the impacts of the MCO tax and, and what that will have. I think also that is absolutely devastating for our not only our providers but for the access to basic care.

So we are, we are going to be in a very kind of seminal moment in the State of California to better understand how we are going to be able to deal with the incredible insidious and evil aspects of HR 1. And I know that we're all kind of girding our loins so to speak. But if there's one administration, agency, advocates, and set of legislators who can do it, I know it's us. So. But I know that we have to get to work. So thank you.

Thank you so much for that. Thank you for the first panel. I appreciate this dialogue. Beginning of many. Moving on to our second panel, the community health impacts of recent immigration enforcement action. Like to welcome our three panelists.

Joining us today is CHIRLA Coalition of Human Immigrant Rights. And we have LA County Department of Health Services with us here today. And then Children and Immigrant Families and Children's Partnership. We'll have CHIRLA kick us off.

Good afternoon, chairs and members of the committee. My name is Monica Madrid. I'm a state policy advocate for the Coalition for Humane Immigrant Rights, CHIRLA. Over 35 years, CHIRLA has worked to uplift immigrant families in California, advocating for dignity, health and human rights.

We're here to speak to the health impacts of the ICE raids, which reverberate far beyond immigration enforcement. Raids destabilize families, inflict trauma and undermine mental and physical health of our entire communities. I want to share a story of one community member that we're working with. Her name is Hasibi Johnson.

On June 17, men dressed as agents came to their home and took Hasibi's brother Fernando. Is it okay if I read in Spanish just because I'm using direct quotes? Okay. According to Hasibi, "El 17 de junio personas decidas de argentes secuestraron a mi hermano y desde que Fernando no esta en casa, mi madre se siente sola." Before the raid, Fernando was the anchor of his family. "Lo llegaba de trabajar, siempre se setaba a la mesa con ella ahora la mesa estabacia."

He showed up at his nephew's school events, sports games, and he shared meals with his mother. And he supported the stability of the household and and his community. Now that the stability is gone, Hasibi told us, "Mucha gente depende de el su negocio

sus amistades sus viejitos se sientan abandonados y me preguntaban cuando va a regresar. Yo solo les digo, estamos luchando. Vamos a regresar, lo vamos a regresar a casa." But the deepest wounds are invisible. Once Fernando returned. Fernando was once a strong man. He is now broken inside. "Eso lo quebro por dentro, tiene miedo de salir solo cuando necesito cuando necesita ver a su abogado,

me llama para que lo acompana no quiere manejar ni estar solo." This is a public health impact of the raids. Anxiety, depression, fear, isolation and lasting trauma. Family like Hasibi are left with sleepless nights. Children lose role models and stability, and elders feel abandoned. Raids create a ripple effect that weaken the health and resilience of entire neighborhoods. As CHIRLA,

we urge this Committee to see raids for what they are. A public health crisis. Enforcement actions shatter trust in institutions, deter families from seeking health care, and leave lasting scars on mental health. California must continue to lead.

We ask you to consider policies that keep families together, protect health and well being, and ensure that no community lives under the constant threat of raids that destroy bodies and spirits.

On behalf of CHIRLA and the families we serve, thank you for holding this hearing and centering health as a lens in understanding the true cost of these ICE raids.

Thank you. Dr. Patel.

Chairs and committee members, thank you very much for this opportunity to speak on behalf of the Los Angeles County Department of Health Services. The Los Angeles County Department of Health Services, or as we refer to it, DHS, is the second largest municipal health system in the nation. It's dedicated to providing extraordinary care to to all people.

Our teams care for more than 750,000 people annually, regardless of insurance, income or immigration status. We provide care in four hospitals, 23 clinics, two ambulatory surgery centers, correctional facilities and directly on the streets through mobile care teams. We provide comprehensive primary specialty and emergency care.

More than half of our patients have a primary language other than English and the majority of those speak Spanish. We provide services for our multilingual patients and immigrant communities using in person patient navigators with multilingual patient navigators, medical interpreters capable of accessing up to 200 languages, and culturally responsive mental health care.

We are the largest provider of care for the uninsured residents in the county and operate two of the Level 1 trauma centers in LA County. These trauma centers serve as critical safety nets for the 10 million people who call LA County home, not just those who are underinsured or uninsured or insured by Medi Cal, but for everyone.

With a workforce of over 30,000 and more than 4.4 million patient visits a year, we're a cornerstone of the region's health infrastructure. We, like many, have been impacted by immigration enforcement. Heightened immigration enforcement activities have led to increased fear and avoidance of public spaces and including health facilities.

In the last two months we have seen some declines in ED and urgent care visits, and communities with large immigrant populations such as the San Fernando Valley, East La, South LA have shown measurable drops in clinic visits as well.

We have been told by numerous patients, community partners, advocates staff and the County Office of Immigrant affairs that people are afraid to venture out for daily necessities and for health care. We can't point to a single cause for the declines in patient visits, but we know that these must be contributing.

Many families, as I noted, regardless of immigration status, are expressing anxiety and hesitation to seek care and to leave their homes. We are also hearing from frontline staff that families are delaying or skipping critical in person care and I can relate that for myself and my colleagues.

We know that walking through the hospitals and the clinics, we see a difference that people are saying when they talk to me that there are fewer people in the waiting room, and I see the same thing when I go in in the morning.

Health services, Emergency departments and urgent care centers Urgent care clinics experienced sharp declines immediately following the initial Ayes enforcement actions that took place in May. Volumes of visits have steadily improved since then.

In the month of June, we saw a Decline in overall ED visits about 14% in comparison to May and in July, decrease of about 10% in comparison to May. In our urgent care clinics, the visits decreased by about 15% in June and about 5% in July in comparison to May.

In efforts to ensure our communities, patients and staff that we are open for business and here to take care of them, we have communicated internally and externally, sending out flyers, communicating in multiple languages, sending out emails to patients who have email addresses to text text messages to patients who have given us permission to text them, and we have put posters and flyers around our facilities indicating that our facilities are open for business and our primary goal is always to provide care.

We are not here to cooperate with ICE enforcement and that privacy laws that people may worry about their information being shared with others are still in effect so that we are subject to HIPAA and the California Medical Information act and cannot and will not share patient information without appropriate permission.

We've also been expanding, working to maximize the use of telehealth visits, asynchronous messaging visits, and other remote modalities that patients are able to access to receive the care that they need. Even if they are afraid to venture outside of their homes or to our facilities. We are able to do phone visits, video visits, email visits.

In addition to delivering in person care, we are also working with our health plan partners who are leveraging their resources, including community health centers and telehealth resources, to do the same thing.

I want to note that the declines in visits that we see and we anticipate seeing into the future and the concern from our staff mean that people will receive less care, both of the acute and ongoing care that they need as a result, and their health care, their health, will suffer, their ability to care for their families and their communities will also suffer and costs will go up as a result.

We know that preventive care is cost effective and as patients avoid care or they avoid coming in at the beginning of an acute episode, the ability to and the cost to take care of them goes up and becomes more difficult. Preventing people from accessing the care they need always has an impact both to individuals, families and communities.

We are committed to doing everything we can to ensure that our patients and all the residents of LA County get the care that they need, regardless of the obstacles put in front of them. But we know that these activities from the Federal Government have impact. Thank you.

Thank you. Good afternoon Chairpersons, Members of the Committee on Health and esteemed panelists. My name is Liza Davis. I'm the Advocacy Director on Children and Immigrant Families at the Children's Partnership. We're a statewide advocacy organization advancing child health equity through policy research and community engagement.

I also sit before you as a proud immigrant from Guatemala and a mother of two little girls. Thank you for the opportunity to speak on the impact of immigration enforcement on California's children. Today I want to highlight a critical but often overlooked issue.

How immigration enforcement disrupts children's access to early childhood education, also known as ECE, and schools spaces that are essential to their health and development. Why this matters in addition to access to medical care, children's health is shaped by social, emotional and family well being, safe neighborhoods, nurturing, nurturing relationships and supportive learning environments.

ECE spaces and K through 12 schools are amongst the most important environments for building this well being. They are often the first community spaces outside the home where children learn social, emotional skills, experience belonging and connect with critical supports. When immigration enforcement reaches into or near these spaces, it undermines every protective factor that children rely on.

Here's what that looks like after recent deportation sweeps in the Central Valley, a Stanford study found a jump of 22% in school absences across several districts, parents kept children home out of fear they might be separated.

In Los Angeles, a 15 year old disabled student was mistakenly detained at gunpoint by Border Patrol agents near his high school, an undoubtedly traumatic incident that highlights the dangers of enforcement near school zones. In ECE spaces, providers like Elida Cruz in Central California tell us parents are too afraid to leave home.

She now delivers groceries and uses code words with families just so they feel safe opening the door. She worries that if families withdraw entirely, her program will collapse. These are not isolated incidents. They show that when immigration enforcement reaches into sensitive locations like schools and ECE spaces, it dismantles the safe, stable environments children need to thrive.

This threat is not only to families, but also to the workforce itself. Already, the ECE sector struggles with low wages, high turnover and chronic understaffing. Immigration- Immigrants comprise of approximately 39% of ECE workforce in California, far exceeding the national average.

A new federal directive to restrict undocumented children from Head Start will further destabilize programs, leaving children without care. So what must we do? One, advance and implement legislation such as AB 495 and AB 49 to ensure children, youth and families feel secure in their schools and ECE spaces.

Two, provide guidance and training to educators and ECE providers on civil protections, immigrant rights and mental health. Strengthening coordination between state agencies to ensure consistent support is a good start. Three, increase and expand state funding for immigration legal services with a specific investment in ECE and K12 school settings.

And four, move to new alternative methodology to set rates that actually reflect the true cost of ECE care, specifically by beginning to fund the cost of care phase in in the next year's budget. California is home to over 4 million children in immigrant families, nearly half of all children in our state.

If immigration enforcement keeps them out of classrooms and ECE spaces, we're not only harming families today, we're undermining California's future. Children depend on us, the adults in their lives, to provide safety, stability and opportunity. We must not fail them. Thank you.

Thank you so much for your presentation. We'll dive into some questions here. I'll kick. Senator.

You're here on behalf of the County of LA.

Yes. Particularly the Department of Health Services.

Okay. Just curious. The County of LA is the largest county in the United States.

Geographically I- Yes, it is.

Yes, it is. So is it possible for you to give us more statistics? You spoke very generally about observations, but you didn't provide any data.

And again, I'm going to stress that as we're out in the community, it's going to become very important that we, at least us as legislators, we need to speak from oh, we're seeing a reduction in the emergency rooms. What are we seeing? Are we seeing 10%? Are we seeing 8%?

As I spoke, we saw a 14% reduction from May to June in our emergency departments.

I just gave that as one example. There were. You. Let me rephrase this. Thank you for coming. You gave an excellent presentation. There were just several points I just threw out emergency room. I didn't write down because I don't have a copy of your presentation. Right.

So you went through several points of observations, but it didn't provide the data. We'd be happy to provide you.

So if you would be so kind as to provide it to the Committee, it would be really helpful because for me, when I'm out speaking, particularly if we're speaking to groups that may not be either one is open to concur with the information that we're providing or to just, you know, flat out deny it.

It really helps us to be able to speak specifically to what we're seeing. Thank you, sir. Do that. Great presentation.

Thank you so much. I think I'll start off with you, Liza. Liza, thank you so much. Yes.

I know you spoke on ECE and I know, you know, we can see the, the connection with health and some on ECE, but I'd like to pivot a little bit more to what we saw, the impacts of COVID on our youth. And can we assume it might be too early for some of the data? Because this is.

We're two and a half months into all of this. Right. It's maybe too preliminary. But are we see, are we potentially going to see the same kind of impact on these kids who have their families detained and follow up to that is, are we having conversations to add this into what the ACE, adverse childhood exposures.

Can this qualify now as an ACE?

Yes. I mean, you know, infant and early childhood, mental health, youth mental health and even the mental health of workforce, of the workforces like the teachers, educators, ECE providers. All of these are things that are coming up on a consistent basis when we're speaking to people on the ground and community members. You're right.

I don't have specific data on the numbers. I do think that there is a strong correlation between what we saw in COVID 19 and what we're seeing now specifically because of the severe isolation, the fear of family separation right now, just not through hospitalization and death, but also through immigration enforcement and all of those.

And so I do think, I mean, one of the ACEs indicators is separation from family. I don't know the exact detail there, but yes, that is absolutely correlated with ACEs. And I do believe that mental health advocates are making that connection and ensuring that they're supporting folks and infra telehealth.

You know, I think, Doctor, you talked about like taking advantage of telehealth options, but are you hearing any digital barrier to that as an option for a lot of these families?

We haven't heard specifically, but we know of course that for people with limited resources that it is, that is going to be a barrier.

This is why the health plans have talked to us about their community health centers where patients can also come in and access the technology they need to do digital visits, telehealth visits, but it still requires them to venture out. And so they may still be apprehensive.

And you mentioned we can't point to a single contributor to the decline you said. But we do know when the decline started, correct?

Well, that's the window that we've looked at May and June. May, June and July so far. Yeah.

So. But is it safe to say that this is an uncommon decline?

I don't know. I'd have to get back to you.

Okay. Yeah, it'd be good just for talking points, to see if this is in abnormality. Is this. Are we continuing to see a decline since January the year before? It'd be good to pinpoint. I know it's hard again to pinpoint to a single contributor, but like, just when the declines really started to happen.

This was brought up to me in my community around this topic about mobile visits into the community. Don't know. Doctor, if you could speak on. Is that possible? I know during COVID we did mobile vaccines. I mean, we had ambulances going into communities and in front of apartments and doing this.

It's possible. It's a question that's been brought up. We currently have a few mobile clinics that we use primarily to service unhoused populations where they are street medicine. Street medicine. There has been some question internally about whether they could be repurposed.

One concern that has been raised is whether the presence of the mobile van will itself cause its own kind of attract attention, you know, will attract attention itself. So something that we will consider and consider whether we can do effectively and safely without detrimentally affecting the other services that were already.

Okay. And then you talked about some of the missed preventative care appointments. So are we saying that we're not seeing a decline in emergency surgeries? Dialysis treatments are happening. It's only on the preventative care?

No, we've seen a decline primarily in emergency and urgent care visits. I was emphasizing that missed preventive care visits have downstream effect.

Okay, so it's the opposite that we're seeing right now. Yes. Okay. And then Lisa, back to you. And maybe CHIRLA, you can speak to this on anecdotal stories. I was just having this conversation a couple hours ago.

About a couple years ago, California was ranked 44 found the Article 44 in terms of the 0 to 5 kids going to see their pediatrician. And I'm wondering if we're hearing that now of parents, undocumented parents, not taking their documented kid to see their pediatrician during this age?

Yes. We're hearing not just fears of going to Doctor's appointments, but also fears and anxieties when seeking legal services as well.

Okay, Is that falling also in the labor and delivery world? Have we heard anything in that space.

I have not. And I take care of newborns, but I have not heard any specifics about labor and delivery yet.

I have not. But I can definitely get back to you.

Okay, thank you.

Thank you for kind of humanizing the moment that we are in. I really appreciate the, the opening of the panel with your question. Your, your comments in particular. Monica, the I just for some context, Alameda County is my district.

It's, you know, there's LA County, Alameda County, Santa Clara County are major hubs carrying a lot of the number of people who are members of immigrant community.

I've spent time talking to several of my healthcare center community healthcare clinics, FQHCs and all of the and I actually did talk to AltaMed as well in LA, in LA, in Orange County area and all of them are experiencing declines that mirror.

Dr. Patel, the numbers that you're talking about kind of in the neighborhood of 15 to 25%, a reduction in access to services, which makes sense.

In my city in Oakland, there was spotting of ICE vehicles and ICE folks in the middle of Chinatown and in the Fruitville district, largely Latino and or Asian API communities and Latino communities respectively. And in the middle of that are our healthcare centers who are struggling with that.

So there's not only the kind of the human impact and I really appreciate that you are saying that people are not going to be accessing care.

There is also the broader issue of the impact that, that not having people access care will have on those health care clinics who are largely funded through their service levels and service provision to people who are on Medi Cal.

So when our immigrant communities are fearful to get health care, it not only means that they're not getting health care, but it also means that we are in this very terrible cycle of not having the ability of our healthcare provider providers to be able to provide that care.

So Dr. Patel, in particular, can you speak to that aspect of the impact of these ICE raids on our communities healthcare systems?

It is more difficult for me to speak to the sort of financial impact on those clinics. Many of them have a slightly different model of reimbursement than we do. If they're doing fee for service, then absolutely they're going to be impacted for us.

Many of our patients are impaneled and we are, you know, they're medical health plan capitated, so we get paid sort of on a monthly basis to care for them. But certainly other people for whom they're, they're on other insurance plans or other fee for service plans, there can be an impact.

The other thing I would like to say about resources, if I may, is that, you know, my day job, so to speak, my regular, the primary part of my job is as the chief of patient safety for the Department of Health Services.

That means that my primary role is to make sure that we provide safe, high quality care and that we don't harm our patients when we're caring for them.

In times like this, I also pick up extra roles like being the department's Immigration affairs liaison when our staff, when our leadership are focused on trying to make sure that our patients and our staff feel safe to receive care, to provide care, and that we are paying attention to things that we need to do to prepare for potential visits from Ayes.

That takes us away from our key mission of providing high quality care to our patients. So there's a drain on resource that is not only monetary but also in terms of taking people's time away from their primary work.

I appreciate that. And I know that there are several pieces of legislation that are being considered that Chirla is a sponsor of to really look at creating different levels of safety or a sense of safety for people who are seeking care going through the Legislature. I know Senator Araguin has one piece of legislation.

I'm sure there are others to be able to address having health care providers understand how to be able to create some opportunity for people to feel safe. I know that we have another panel on the access to healthcare and data sharing pieces. But I did want to just ask you all from your perspective.

There were recent part of the federal enforcement actions not only included include the on the street what is happening in terms of ICE agents showing up, but it also impacted the requirements of the Federal Government of Homeland Security to have access to data from CMS. The federal CMS. That was kind of a known thing that happened.

Very terrifying for a lot of individuals. Can you all speak to that aspect of the Federal Immigration Enforcement actions on the individual experience of people either seeking care or impact on providers?

Again, in addition to what we've said, what I've said before and what I think the others have said as well, that people are very apprehensive.

I was speaking to one of our health plan partners this morning who reported that, you know, they perceive apprehension and they get, you know, reports of people being unwilling to enroll even for benefits that they are eligible for because they're afraid that this may, the information that sort of flows downstream may impact their family members as well.

We're hearing a lot of fears from community members of applying for medical for MediCal, when we're telling people this cap is coming, apply now. Now we're having to pivot and let them know, you can apply now. You should apply now if you want to get MediCal. But then also let them know this is actually happening.

And this is your right. These are your rights. We do know that there are lawsuits about the data leak that are going, that are ongoing and then also where we have like weekly check ins with AltaMed.

And they're constantly telling us that, like, people are fearful to go out and how much this has hurt, like how much hurt that this has done to the community.

And I would say in response to your previous question. Right. That that sort of reminds me that a lot of EDs like ours see patients who may not have coverage, may be available, may be eligible for emergency coverage at present.

And if they're afraid to enroll for it, or if they become no longer eligible, through all of the effects that H R1 has, that will be a decrease in revenue for those hospitals.

Absolutely. I'll just add that the chill effect that the data sharing causes is, is, is even beyond enrolling in Medi Cal. Right. So it's even accessing critical services like WIC, going to Head Start. There's, there's now fear that Head Start has to start collecting certain information in order to enroll families.

All kinds of critical service, you know, dental care, mental health services, all of those things are connected to that chill that happens when people think that they're unsafe in sharing their information or that it's going to be used against them. Very similar to what we've seen in the past around the public charge rule.

Senator Dr. Weber.

Thank you, chair. Want to thank the panelists for being here.

Wanted to kind of piggyback on a point that Senator Menjivar brought up around the data that you were referring to, Dr. Patel, and the fact that you've seen a decrease in the number of patients in the emergency rooms and urgent cares and the issue around preventative care may be too early to have this data that I'm getting ready to talk about, but it would be great if it is a part of the framework that you're collecting.

And that would be even if you have a decrease in the number of patients showing up to the emergency rooms or urgent cares, are you seeing an increase in the number of emergent diagnosis that could have been managed preventively.

So, for example, are you seeing an increase in the number of patients coming in with DKA or, or with a hypertensive urgency or emergency situation that could have been managed preventatively?

I think that's an excellent question and one I've wondered a little bit about myself. We don't have any data on it yet, but I'll be happy to look in to see if we can get that.

Thank you. Was that diabetic ketoacidosis? Yes. Tiny EMT knowledge. Tiny. Okay, great. Thank you. Thank you so much. I appreciate it. I think I thought it was really important for us to do this intersection between what is happening and then it really putting the public health lens under it.

I know we're going to continue to have ongoing long term impacts both to the children of families detained and to those detained as well especially. I mean we heard stories last week during a Senate roundtable of people who are detained missing chemo appointments.

So just their diagnosis deteriorating while being detained with because they don't have access to their healthcare needs. So ongoing or women who are being detained right now are not being given feminine hygiene products during days and days and weeks of detainment. So there is a public health lens, an umbrella to these raids.

So I thought it was important, we thought it was important to bring that conversation forward. So thank you so much for your participation. Our final panel is going to be on the federal administrative changes affecting access to health care and data sharing. We have two panelists joining us today.

The California Immigrant Policy center and St. John's Community Health will be with us today.

Please go ahead and start whenever you're ready.

Hi. Good afternoon. Jim Mangia, President and CEO of St. John's Community Health. We're a nonprofit, federally qualified health center in Los Angeles in the Inland Empire. We provide medical, dental, behavioral health services. We have 28 clinic sites and five mobiles street medicine team, a large transgender health program.

And we're the largest provider of services to undocumented immigrants in the country. Our patients are facing a deluge of attacks. We spoke earlier in this hearing about the impact of the ICE raids.

Not so dramatic, but equally as chilling for our patients were the recent moves of the Trump Administration to redefine and broaden the definition of public charge and the exchange of private health data in the medical system with immigration authorities. This is having a profound impact on access to care for our tens of thousands of patients.

In the last month, hundreds of patients are declining to re-enroll into Medi-Cal for fear of public charge. Our call center was inundated with calls from immigration immigrant patients asking if their names and addresses were shared with ICE. One day last week alone, there were over 800 calls to our call center asking that question.

Since the immigration raids and the information about federal administrative changes, no show rates and appointments have tripled, going from nine percent of our patients missing their appointments to over 31 percent. As the raids have dissipated a little bit, the no-show rate is declining again, but it's still higher than it was before.

We called our patients to find out we have about 25,000 undocumented patients. We called them to ask them why they didn't come, and they said they were afraid to come because of ICE.

So we developed a program called Healthcare Without Fear where we send doctors and nurses, and medical assistants to the homes of our patients to provide on-site healthcare services. We're also delivering their medicine, and we also found that many families were afraid to go to the grocery store or didn't have money to buy food.

So our doctors are bringing bags of groceries with them as well. We've seen close to 600 patients so far in the last three weeks in this Healthcare Without Fear program. We're also seeing a lot of patients whose chronic diseases and other health conditions are getting significantly worse as a result. One of our patients, we have diabetes classes that provide exercise and fitness community, and we have demonstration kitchens to teach patients how to cook their favorite foods with healthy ingredients.

One of our patients, who has been coming to this diabetes class for years, her health has gotten so good that the doctor was about to take her off her medicine was undocumented, and was afraid to come in for a visit. We contacted her visit, visited her home.

Her blood sugar level was literally on the verge, was high enough for her to be on the verge of a diabetic coma. And we asked her what had happened because she had been doing so well. And she shared that she didn't have any food and that for the last eight days, she'd only eaten tortillas and drank coffee.

So these are the kinds of situations that we're seeing. And in the midst of all this, our street medicine team was at MacArthur Park a couple of weeks back when ICE made the pseudo-military operation.

They shut down our street medicine program, threatened our patients, and put machine guns in the face of our doctors and medical assistants and forced them to leave. So, obviously, it's very difficult on the ground.

And I want to be honest here today, I think what we're really not talking about is the impact that the state cuts are going to have on the communities that we serve. The state cuts are actually three times as bad as the federal cuts. Three times as many people will lose their health coverage.

When we're talking about a proposal that starts in July that would cut 80% of the funding of the rate that FQHC's nonprofit health providers receive, we serve the majority of undocumented patients in California.

When you're talking about a family of four with Medi-Cal income eligibility, the highest income eligibility is 2,600 dollars a month for a family of four.

When you're talking about a studio apartment for 1900 average in LA, and you're talking about, now that patient having to pay 30 dollars per person, 120 dollars a month to keep their Medi-Cal, they're not going to pay it.

And so what we have to address is that while our families are facing these attacks from the federal government, they're facing these raids, they're facing these administrative situations, they're facing these increasing cuts in the federal Medicaid program.

And at the same time, the state is significantly cutting their access to Medi-Cal and is decimating nonprofit federally qualified health centers in the process. So I really would urge that we consider a revenue option rather than cuts.

If we just Institute taxes on the billionaires who got a tax break under Trump's law, we could bring in tens of billions of dollars to the general fund and literally avoid all the cuts and, in fact, backfill all the cuts coming from the federal government.

And so the people of California would not feel any of the effects of the big, ugly bill. But thank you so much for indulging me and for allowing St. John's to be here today. Thank you.

Thank you so much. Carlos.

Hello Chairs, members. My name is Carlos Alarcon, and I am a Health Policy analyst with the California Immigrant Policy Center. For more than a decade, CIPC has been proud to co-lead the Health for All Coalition, which has been the main driving force to expand health care our healthcare system to include all Californians regardless of immigration status.

Our immigrant community has been deeply affected by the impacts of the passage of HR1. Today I will be discussing the impacts on public charge concerns that we're hearing from our community on the ground and what we know so far about data sharing with Department of Homeland Security and ICE.

Starting with public charge, this is a test applied when immigrants seek to adjust their status.

During this evaluation, a government official and immigration official decides whether this individual is likely to become dependent on government assistance long-term for programs like Supplemental Security Income, Temporary Assistance for Needy Families, General Assistance Relief, and Medicaid for long-term medical care in an institution like a nursing home or psychiatric hospital.

If someone is deemed a public charge, they can be denied the ability to adjust their status. This creates a fear in immigrant communities from accessing basic programs. Now, the majority of the immigrant community does not qualify for these public benefits to begin with.

But HR1 kicks almost all immigrants, almost all immigrants without a green card, off of the few benefits that they did qualify for. Now these changes reduce the impact that public charge has. However, it's the fear that impacts our communities the most.

Even years after the medical education and enrollment campaigns that we did, the fear of public charge still haunts our communities to this day. And these fears have been even multiplied by the reports that HHS is providing Department of Homeland Security access to the records of all people who have used Medi-Cal, even if only for emergency services.

And to answer your question from the previous panel, Madam Chair, people are scared. Rightfully so. People are scared that Ayes will know where they live, will know where they get their health care.

They are scared that ICE will stalk their homes or their hospitals and wait until they are no longer in a private area to kidnap them without a warrant. At first, community members would weigh the options of switching from in person appointments to telehealth appointments.

But now we have community members who are contacting their health centers and their enroller organizations and asking them to disenroll them from Medi-Cal coverage. Then these individuals will potentially be subject to the Medi-Cal enrollment freeze in January 1st, 2026, meaning they will be frozen out the program entirely.

We are even hearing that some Latinos with lawful status are questioning if they should disenroll from Medi-Cal themselves due to how racially targeted the ICE raids have been. They don't want ICE to see a Latino last name in the database and then going after them or their family who may be undocumented.

And if an individual disenrolls, that will not necessarily protect their data. Since we don't know the extent to which how much information HHS has already shared with ICE. Because of the attacks on our immigrant communities' access to medical in both the federal and state budgets, our community members are having a hard time keeping track of it all.

And they are having an even harder time deciding what the proper decision for their healthcare situation is. Last month I was contacted by a community member who needed a surgery. They wanted to enroll in Medi-Cal, but they are concerned about the data sharing, rightfully so. He didn't want his information shared with ICE.

He wanted to wait to see how this played out in the courts. But because of our state budget decisions, this individual is now forced to choose between their health or their safety, because the medical enrollment freeze is looming ahead. Look, now more than ever, our immigrant communities' health and safety is under threat.

Whether it be from our access to health coverage being stripped away or because we're scared to step out of our door due to the violent immigration enforcement. California must once again champion policies that catalyze our public health system forward rather than freezing our communities out of it. Thank you so much.

You two were phenomenal. Thank you so much for just how candid. And you know, you didn't sugarcoat anything, which is that it's the reality for so many Californians right now. So I do appreciate you coming and bringing those, elevating those stories. Senator.

Thank you, Chair. I want to thank you both for coming to present before us today. We are definitely in difficult times. It was not, you know, easy state budgetary issues, and we don't know the full impact because we will be having some significant cuts as the first panel highlighted from the federal government.

And so what we're able to do is extremely limited at this point. But your program, Healthcare Without Fear, is intriguing. So, you know, because I've been hearing a lot that people are afraid to even open their doors to people who come.

So I was wondering how, how are you able to get those patients to open the doors and allow the providers to come into their home to provide the care that they need? Are these their, their doctors that they've been seeing, so they know them?

Is it something that you're, that you're sending out or calling to the patients in advance? I'm just trying to figure out how you all are able to make it work, because I think it's excellent that you've done this. But how do you have that trust for that particular patient to let you in?

Thanks for that question. I think that as federally qualified health centers, obviously, we're very ingrained in the communities that we serve. We decided when the Trump Administration first took office that we were going to call. We knew something like this was coming down, some of these ICE raids or attacks on immigrant families or on their health care.

So we started calling all of our 25,000 plus patients who we know are undocumented, and we asked them what their greatest fears were and what kind of services they would be willing to access.

And so we had a sense going in before the raids really started, we had a sense of what was on the minds of our immigrant families.

So when the raids hit, we immediately began calling those patients back, particularly the patients who didn't show or cancel their appointments, and ask them if they would be willing to have a doctor visit their home. And again, we called thousands of patients, and we called hundreds every day who had missed their appointments.

And many of the patients, probably half of the patients, said no and requested a telehealth visit, but about half of the patients said yes. And so those are the patients that we visited.

Thank you for that, and thank you for being so proactive in one, realizing that this could be a potential issue, but two, also coming up with a very quick solution so that your patients aren't missing out on the health care that they need, whether via telehealth or actually in person.

Do you see a role for not only with your hospital but or your clinic, but just in general within the healthcare space of starting to have more collaboration with like community-based organizations, because that trust is extremely important. And like you said, it's a federally qualified health center. You're there in the community.

That's not necessarily the case for every clinic or every hospital. So do you see a role in the future in needing to strengthen those relationships in case we need to do more of what you're doing?

Yeah, I think that's a very, very important point because St. John's has been there a long time and we have very deep relationships in South LA and East Los Angeles, and we work very closely with CHILA, we work very closely with CPIC, and many other community-based organizations, particularly community-based organizations in the LA area and the Inland Empire.

And so, that has helped a lot because a lot of those organizations have reached out to their clients, many of whom are patients of St. John. So, it was kind of a joint effort that allowed us to reach those patients.

One thing I do want to point out is that we did call the Department of Health Services to see if we could get reimbursed for those home visits, and they said no. So we are currently doing that without any reimbursement whatsoever, including the delivery of medicine.

Thank you for that.

Jim, you mentioned you started talking about the incident at MacArthur Park in the previous panel. We talked about the possibility of replicating street medicine like we do with the unhoused population to this population, but we could encounter additional incidents like you did.

So would you say is this not the solution to get care to this population during these times?

I think we have to try multiple solutions. We do have mobiles that are going out on, you know, and we're contacting neighbors in the immediate surrounding blocks, and they feel a little more secure in a residential area to come out and access the mobile.

But we've had our mobile hit by ICE in addition to MacArthur Park, another time where we literally, our security. We've done a lot of trainings with our staff, of course, and our security guards.

Quickly, we were at an alcohol and drug recovery center in Downey, and ICE pulled up, and we immediately closed the gates and moved the patients into the mobile. But the mobile has been. We haven't had our clinics hit, but we've had ICE approach several of our mobiles on several occasions.

So the mobiles seem to us to be a little more vulnerable. But we have taken them into, like, a residential block and then contacted all of our patients on that block and had them come out. And that has worked.

But, you know, we had to make sure we had a lot of security because patients wanted to know that they had a buffer between a potential ICE intervention in the clinic space.

25,000 individuals. They knew they were undocumented. But I've heard from other entities that they don't know who is undocumented, that they serve in their clinics. How were you able to get that data? And can you still, do you still know which of your clients or patients are undocumented?

And then you spoke about you were able to call those 2,500 or.

25,000.

Well, the benefit of being in Los Angeles County is that prior to the expansion of Medi-Cal to the undocumented population in California, there was a program called My Health LA, and that program was specifically for undocumented immigrants who were not eligible for Medi-Cal. And so that list is what we use as a basis.

And I'm sure there are more. There were patients that were missed, that some of those patients obviously dropped off in the medical transition, and there were new ones that joined, but we had a core list of patients who we knew were undocumented that we were able to reach out to.

Yeah.

I remember that program, actually.

Carlos, you gave a story regarding one of the individuals making that decision. Anecdotally, as you're hearing, I don't know if you're hearing more of those scenarios. Are individuals opting to sign on, given that restriction coming up, or are they opting to not sign on?

Sometimes it's 5050 really, like, they come to us asking for information. And as an organization, the best we could do is give them the facts. Right. Giving them the knowledge of this happened.

And by this, I mean CMS sharing the data with Department of Homeland Security and also letting them know what options they have to enroll in Medi-Cal and letting them decide, really. And I've seen it go either way.

So are you, I mean, because I've been struggling with that talking point, that messaging as well, is I want my community to have access to health care, but they need to know also, if they sign up. Right. They could be on the list. So in your.

Yeah. Letting them make the best decision for their own health care situation.

Without leaning do this to that.

I, I try not to, right. But, like, if an individual tells me, like, how severe their condition may be, I might like, hey, given the situation, maybe enrolling in medicom might be the best decision. Right. But again, I try to, like, not lean them one way or another.

And again, it's 50/50 people are like, I'll just wait for the court case. And I'm like, that's perfectly fine. Just know come January 2026 an enrollment freeze is coming.

All right, thanks.

I think. Thank you for sharing that particular example and some of the impacts that you're seeing.

And my question to one of my questions to the first panel was around perhaps a little muddled in my questioning what the interaction or the interplay between the recent changes or budget decisions that California made in advance of HR1 and whether there are aspects of what we've already moved forward with our proposal that need to be reexamined given the existence of HR1.

I think that you're hitting on one of the areas where there is just a natural tension, right. If we and Chair mentioned this as well, where we want to be Able to ensure that people are enrolling prior to the Medi-Cal enrollment freeze that we needed to implement to, well, that we adopted.

But then that also kind of puts us in tension with this idea that people want some certainty around the protection of their, of their data and their privacy so that they will not be more vulnerable to being exposed to the, the actions of the federal government which by the way are sweeping up people who are documented undocumented of legal status of you know, they're sweeping up people who are black and brown and our API communities in record numbers in many instances non discriminately.

So it is very important for us to kind of look at those areas where there is natural tension kind of built in, seeing what the federal administration has done around immigration enforcement, around the aspects of HR1 so that we can go back and see whether or not there is some harm mitigation that we should engage in as a legislature.

So I really appreciate you bringing up that very concrete example to be able to have us perhaps look at our efforts there to see what kind of tensions there are.

Are there any other areas where you feel like there is a natural tension between what you are saying from health provider perspective around HR1, and where California has already made some decisions to take some actions to be able to deal with the overall cost of healthcare?

Well, I think that that's a hard question, very thoughtful question, but a very hard question. I think that everybody knows in the communities that we serve that the Trump Administration is going after immigrant communities and that they are coming at them in many different ways.

In addition to the raids, the data sharing, the administrative, the changing of public charge again. But I think what people are most surprised by is the state now instituting a fee, freezing enrollment, and cutting Medi-Cal services for immigrant families as well.

So I think that is, I think a lot of families and certainly as an FQHC provider, we thought that we would be safe in the State of California. We thought that the governor and the legislature would protect those gains that we had made. And so I mean there are, I mean we're start.

We're part of the formation of a committee, of a coalition to put look at the possibility of putting an initiative on the ballot to bring in revenue to backfill the cuts from the feds and also allow the state to prevent making those cuts themselves.

And what we're looking at is that the tax on the rich in California, commensurate with the amount that they saved through the feds, could bring in anywhere between 80 billion and 150 billion dollars, which is way more than the 12 billion dollar deficit we're looking and essentially would end the deficit for the State of California forever.

So, you know, if we have to do that ourselves, obviously with partners in labor, and then we will, but obviously it would be a lot less expensive and a lot easier if the legislature would either do that, and if the governor refuses to sign it, then to put that on the ballot.

I think we could save, and I think it would be a real strategic move on the part of the State of California to say to the rest of the country, we are not accepting this. We are not going to allow Donald Trump to dictate how our families in California are treated.

And we are going to make sure that all of those cuts that you're making on the federal level are restored. We're going to backfill.

I mean, in LA County, we're looking at the Department of Public Health, Department of Health, sorry, the Department of Health Services alone is looking at closing a public hospital and laying off 5,000 workers, union workers. We can't allow that to happen, I think, in this state, and we have the resources.

I don't think I really answered your question, Assemblywoman. I'm sorry, I can't grasp the specifics of that correlation yet. I have to give it some thought, but I understand where you're going, and it's kind of here, but I can't have to think a little bit about it. I'm sorry.

Well, I do appreciate what you did offer, and I think it was brought up in the first panel as well. We are in a moment in time where California absolutely needs to be responsive to the moment. We are stepping up in that way around another area related to redistricting.

We know that we are doing that right now, and it is entirely because of just needing to be incredibly responsive to the potential destruction of our democracy. Don't say that lightly. That's why we are doing that.

I do think that we need to recognize the enormity of the situation that we're dealing with as it relates to our health care system, with as much intention and creativity to ensure that we keep Californians and the progress that we've made around our health care system.

So I appreciate you offering one potential alternative that we, that we need to engage in, and that's more on the revenue-generating side, which we've spent a lot of time discussing as well. And I'm sure we will come up with some other solutions that have to do with the healthcare savings side as well.

Yeah. I also did want to thank the legislature for postponing many of those cuts because it does give us a window and it does give us the opportunity to look at some other solutions. So I think that was a very bold and important move that gives us the time we need in order to figure out a solution.

Gentlemen, thank you so much for this dialogue, I appreciate it. Look forward to ongoing conversations on this.

Appreciate that. Thank you, Chair.

Thank you so much for inviting us.

We're going to now turn to public comment.

If we could keep it under two minutes, please.

Thank you very much. Vanessa Cajina with KP Public Affairs, on behalf of a number of clients. I don't know where to start today. This is overwhelming in a way that I haven't seen in my entire career.

I can say that in terms of programs of all-inclusive care for the elderly, the things that we're looking at, where we need to be proactive is how we get nimble and thoughtful about eligibility redeterminations, where we can be looking at places where we can save money on the front end on preventive care for people with especially high chronic conditions and better ways to improve that care.

Some of the functions within the Department that we've been talking about, I think that there are some opportunities there for us to partner and tell you with some anecdotal evidence for the California Academy of Family Physicians, one of our member clinics in the Central Valley told us that last week, they had a 40% decline in appointments.

Those were cancellations. This is primary care.

So, as we look and think about the data sharing and the data collection that we can do in a safe way, we've got to be looking at both the primary care front end and then also the emergent care and the continuity of care that needs to be going on with all of that.

And family physicians are critically, critically concerned, about all of these changes and are there to partner with you and really appreciate the comments from St. John's today.

I will leave you with a glimmer of hope that I had today is that for Vision Compromiso and the 4,000 promotoras de salud around California, they can be those puentesd de salud, those puentes de comunidad, to make sure that people are getting what they need.

Let's think about how to be creative with some of the reimbursement methods that we've already thought about here in California. We set that stage. Let's keep it going. Thank you very much.

Thank you.

Good afternoon. Laura Lane, on behalf of the California Association of Public Hospitals. Thank you, Chairman Menjivar and Chair Bonta, for convening this hearing and for your leadership in addressing the serious concerns facing our public hospitals and health care systems. HR 1, as you heard, cuts nearly $1 trillion from Medicaid over 10 years.

That's about $250 million every day ripped from health care funding across the country. HR 1 threatens the foundation of California safety net systems. Our 17 public health care systems serve 3 million patients with 10 million outpatient visits annually, providing 35% of all MediCal and uninsured hospital care and running over half the state's highest-level trauma and burn centers.

The financial impact is devastating. By 2032, just the impact of state directed payment cuts, which we didn't even talk about today, will result in a $2.3 billion net loss annually to our systems.

When combined with other looming federal cuts and state budget cuts programs serving undocumented immigrants, we're looking at more than $7 billion in lost funding annually while simultaneously serving millions of additional uninsured patients.

HR 1's eligibility changes could strip coverage from up to 3.4 million MediCal members, creating a surge in uncompensated care, precisely when our funding is being slashed. This isn't theoretical. Closures, service cuts, and layoffs are practically guaranteed. And the collapse will cascade far beyond our public systems to overwhelm every hospital, clinic, and emergency room in the state.

We need your partnership to develop strategies that preserve coverage, protect patients, and prevent further cuts to California's healthcare safety net system. Further, we urge you to reaffirm and strengthen California protections that keep healthcare settings safe for all patients and help us work to rebuild the trust with families in our communities who are still afraid to seek care.

Thank you so much.

Thank you.

Good afternoon, Madam Chairs and member. Connie Delgado, on behalf of the District Hospital Leadership Forum. These are the 33 district and municipal hospitals in this state. Two thirds of these hospitals are located in rural communities and 18 of them have critical access designation. I just wanted to add very quickly.

I know that you did mention distressed hospitals and kind of the current state, I want to let you know that these hospitals received 50% of the pot that was allocated for the Distressed Hospital Fund. So, these hospitals are struggling now.

HR 1 will jeopardize the future of these hospitals, increasing the uninsured populations, which we've heard a lot of discussion about today, in the communities, while cutting MediCal funding streams that serve all lifelines for rural and safety net providers. These federal changes are rapidly approaching.

And while hospitals are doing everything possible to prepare, they are simultaneously grappling with state budget reductions and new mandates that increase costs without providing funding. This combination makes survival nearly impossible for hospitals already operating on the thinnest of margins. We're talking minimal days, cash on hand. We discuss this in various forums.

When a district hospital closes, patients lose local access to emergency and inpatient care, communities lose their largest employer, which we've had conversations today about the workforce, and the state loses critical health care infrastructure.

We want to urge the legislature to stand with us, oppose federal cuts, avoid adding additional unfunded mandates as they move through the legislature, and partner with us on solutions that preserve access to care in rural and underserved communities, and thank you again for this conversation.

Hello, my name is Beatriz Hernandez and I'm here with the Health for All Coalition. I'm an undocumented Californian. I don't have DACA and I'm fully undocumented.

Through the Medi-Cal expansion for undocumented young adults, I was able to avoid paying thousands of dollars for my university's private health insurance because I was finally able to have my own coverage. That is why I'm so alarmed by the rollbacks we're seeing. We cannot afford to wait until harm happens before taking action.

This year, the legislature only approved legal services funding after ICE raids and kidnappings started to happen in LA. Please don't make the same mistake with health care. We need you to restore health for all, Medi-Cal for undocumented Californians with no rollbacks, before we start seeing devastating impacts across our state.

And finally, I urge you to not delay revenue conversations until 2027. As noted in the budget package earlier this year, our communities need solutions now to protect the health and safety of all Californians, regardless of immigration status. Thank you.

Nicette Short representing PEACH, the Community Hospital Safety Net. We appreciate this hearing and your leadership and your genuine and warranted concern. As your panelists clearly noted today, our system of care and our patients are in serious jeopardy.

We appreciate that today we broached the conversation of relief and kind of how to work together for the future. We all need to work together to find those opportunities to provide that needed relief and support for our community hospitals to help them survive and care for our vulnerable communities. Thank you so much.

Good afternoon. Whitney Francis with the Western Center on Law and Poverty and on behalf of End Child Poverty in California and Coalition for Humane Immigrant Rights. In addition to my colleague's testimony today, we oppose hostile federal ICE and data intrusion actions that will instill fear within our immigrant community, and we oppose HR 1 funding cuts targeted at immigrants and urge the state to step up to fill in the widening coverage gaps in this year's state budget, and as a result of federal actions.

We know that people today face numerous challenges in accessing MediCal, including language barriers, complex paperwork requirements, and misinformation during renewal processes, which will be exacerbated.

We urge the legislature to support policies that minimize the harms of HR 1 and reduce barriers to Californians' ability to keep their health care reflection, regardless of immigration status. A specific policy solution to mitigate HR 1's impacts is to simplify today's currently burdensome manual processes by reimplementing the MediCal winding flexibilities, which have been proven to increase automatic renewals and reduce procedural terminations.

We look forward to working with you and thank you.

Good afternoon, Chairs and member. HR 1 is—Omar Altamimi with the California Pan Ethnic Health Network—HR 1 is a serious threat to the health care of California's most vulnerable populations, threatening to exacerbate disparities faced by California immigrants and communities of color.

Policymakers must stand ready to develop creative policy solutions such as automation in order to mitigate the damaging provisions of HR 1, which seek to undermine and destroy our health care system by adding unnecessary administrative hurdles to maintaining health care coverage on top of cuts the legislature made largely to immigrant families in this year's budget.

HR 1 will mean more people losing access to health care as a result of burdensome new reporting requirements that will unfairly target women and caregivers, many of whom are already working. As a result, people will be living sicker and dying unnecessarily from illnesses that could have been prevented.

It expands the categories of immigrants ineligible for federal funding, those considered to be UIS, which unfortunately was also baked into the state budget eligibility changes.

And it changes how provider taxes can be leveraged and raises questions about whether Prop 35 should continue to be implemented as written, or whether we must go back to the voters to avoid additional cuts to access to health care in the future.

These changes and disruptions to the health care system will also mean more Californians end up with medical debt. We're going to need policymakers to focus on making sure we maintain a strong safety net for those who need it.

As we work towards implementing HR 1, we need policymakers who put the health care of Californians first, must put people's health before profits, increase revenue, and look to alternative funding sources while we also hold industry accountable to keep access and coverage intact. Thank you.

Good afternoon. Amanda Kirchner on behalf of County Welfare Directors Association. I want to thank the committee and your staff for putting on this really important hearing. As counties, we are going to be on the front lines of the implementation of HR 1 and we're going to see firsthand all of these policy decisions coming into effect.

There are a few things, more than a few things, that we think are going to be challenges that I'd like to highlight.

First of all, of course, is going to be the work requirements and making sure that we are able to leverage the data between CalSAWS for our Medi-Cal work requirements alongside CalFresh and CalWORKS, being able to make sure that those programs work together and that as the complexity builds for Medi-Cal, we are also being able to train our workforce.

As this program becomes more complicated, it's more complicated for our staff to implement, it becomes more difficult for our customers to meet the needs and the eligibility requirements. And so, part of an additional concern out of that is also the timing of the federal guidelines that should be coming down.

We are not particularly nimble when implementing things, especially new things like this, and it's really critical that we have enough timing to do this right.

And so, by doing so we'll be able to hopefully mitigate some of that churn, that I know the director was talking about, that you have mentioned, and making sure that people aren't just falling off for paperwork or procedural reasons.

I also want to highlight, of course, there are challenges between our state and federal budget and the freeze coming up in 2026. That's going to be a problem as well.

And just generally, any of the future policy shifts that may also come down because of HR 1 or from the federal government, we will have to, of course, implement those as they come out and that will also impact how we work with our customers.

So, what we're asking for and hoping that we can work with the legislature on is being able to design the work requirements and the automation processes to leverage the data sharing across CalWORKS, CalFresh, and Medi-Cal. We're also hoping to maximize federal flexibilities that will be allowed. Thank you.

Hi, my name is Mandy Deese. I'm with Southeast Asia Resource Action Center: SEARAC. Thank you so much for holding this really important hearing. At SEARAC, we define Southeast Asians as refugees and immigrant communities from Laos, Cambodia, and Vietnam.

In 2025, this year marks 50 years since our communities resettled into this country, and today, we are witnessing an increase in community members getting detained and deported, including into countries that are facing civil war and that they have no support systems and these are folks who actually fled wars and genocide to come to the state of California.

California has the largest share of Southeast Asian Americans, including Laotians, Cambodians, Vietnamese Americans, and many, many minor ethnic groups under that umbrella.

And as survivors of war and genocide, Southeast Asian Americans still face increasingly disparate health outcomes, including higher rates of physical, mental, and chronic health challenges, including 60% of Cambodian Americans who continue to experience post-traumatic stress disorder from the violence and war in Southeast Asia.

Nearly half of the community receives Medi-Cal or some form of public health insurance in California, and we know that community members, already underserved and facing many, many challenges to access health care in our system, are even more reluctant to access health care, even though community health centers and through health navigators that they know and trust.

So, our ask is to please make sure that California continues to support policies that result in the safety and health of all Californians and to take a holistic lens on what health care means in our great state. Thank you.

Good afternoon, I'm Erin Evans-Fudem with the County of Santa Clara. Santa Clara County is one of the most diverse places in the country. More than 40% of our residents are foreign born and more than 100 languages and dialects are spoken in the community.

Fear of federal actions has already impacted the health and well-being of our community members. And with the passage of HR 1, tens of thousands of families in the county will have a harder time accessing critical care and benefits.

HR 1 will create—well, because we operate a large public hospital system, HR 1 will create a $500 million hole in our county budget in the next year, doubling to over $1 billion in three fiscal years. The county is doing everything it can to avoid catastrophic cuts.

Earlier this month, our board of supervisors placed a general sales tax measure on the ballot asking our community to help. Before HR 1 passed, we started using local funds to pay for threatened services, including gender-affirming care and some services for undocumented immigrants—residents, excuse me. Even with these measures, we will need help.

We look forward to partnering with you. HR 1 and continued federal operations risk our community health now. Thank you.

Good afternoon, Chairs and committee member. Kathy Mossburg on behalf of Essential Access Health. Want to just clarify, just talk about the passage of HR 1 marks the most extreme and far-reaching attack on health care access in modern US History, and as you've heard today, that will decimate the Medicaid program.

Particularly, want to talk about the defunding of Planned Parenthood and what that means for other abortion providers as well. Medicaid covers 70 of all publicly funded family planning care.

By banning abortion providers from participating in Medicaid, the law not only enacts a nationwide backdoor abortion ban but also robs millions of people who rely on family planning services as their primary source of care and access to birth control, access to STI prevention and treatment, cancer screenings, and other essential preventive services.

Essential access stands in solidarity with our partners and urges the state leaders, sorry, to step in to protect providers being directly targeted, minimize harm, and continue to bolster capacity of providers across the ecosystem to ensure that options and pathways to access high quality sexual and reproductive health care continue to exist. Thank you for your time today.

Nora Angeles with Children Now. We'd like to thank you for holding this important hearing today and we look forward to working with you to ensure that all Californians, children, family, and youth are able to access health care. Thank you.