Assembly Budget Subcommittee No. 1 on Health

Good afternoon, and welcome to the Assembly Budget Subcommittee on Health. We are gonna make some adjustments to today's proceedings. We're originally gonna start with our joint hearing. Instead, we're gonna start with the sub one regular order of business. And then when our Senate colleagues are able to join us, we'll recess subcommittee one and begin our notice joint hearing on access to gender affirming care.

Then once the joint hearing concludes, we will come back and resume sub one's proceedings. And, one of the reasons we're doing this is we have over 40 witnesses and technical experts, for the hearing today. We have seven topics, just a momentous amount of information. And so to be respectful of the public's time that is here and that is watching, we wanna get started expediently and be able to move through both hearings. So we're now gonna convene our regular assembly budget subcommittee one hearing.

And if committee staff, if you could please call the roll.

[Roll Call]

And we do have, we have quorum yet? We oh, we're we don't yet have quorum, so we will continue as a subcommittee while we're waiting for other members to arise. So this subcommittee has focused on HR 1 both this year as well as last year. We were anticipating HR 1.

This is our third hearing looking at what HR 1 or the big beautiful bill has meant to millions of Californians, 15,000,000 actually, who have Medi Cal, another 1,600,000 who have covered California, and what HR 1 is doing to those folks, and how California is navigating that.

We've examined the impact of new restrictions on medical student loans, so people who wanna become doctors who need to take out loans. We've also looked at residencies in California and the downstream impacts on physicians and health care delivery. And as a reminder, HR 1 restricts med school loans. And so we started our first hearing with that because so many Californians are having trouble accessing primary care doctors within their communities. We've also heard about the consequences to safety net programs across California.

But today is our third hearing on HR 1, and by far, it's our most extensive, I think, covering six issues across a wide range of programs and topics. And we're gonna be talking about infrastructure, the health care safety net, which is not just about having health care coverage, but also about how you can be seen at a hospital, a clinic, how the counties and the providers actually deliver care.

And we know that HR 1 is making sweeping changes that are upending the financing of our health care system and our health care system as a whole from the managed care organization tax to hospital fees to state directed payments. So we're gonna be talking about this. We're also going to look at reproductive health care, long term care services, and supports as well as medical dental that we've heard from a number of people.

And throughout the hearings, I would say we've tried to bring voices, first person voices from across California to testify so that we're hearing both from, Department of Finance and the administration and the LAO, but also from regular everyday people and how policies here in California and budget maneuvers here in California affect people's real lives. So today, I wanna say thank you to all of the panelists that are coming. As I mentioned, we have over 40 witnesses and technical experts that are here.

And due to the volume of testimony, we're gonna ask everybody to keep their testimony to a three minute Max, which I know is hard to do. But I think you got a heads up about that.

And so would very much appreciate if you could respect each other's time by keeping your testimony as short as possible. In addition to accommodate space at the witness table, we're gonna ask LAO and DOF to sit at the edge of the dais if, the table becomes full so that we can have you up here, but also have room for anyone testifying. With that, I wanna see if there's any committee members that wanted to make opening remarks. And if not, we'll jump into the agenda. Okay.

Not seeing, any comments here. We are going to start, with our subcommittee hearing that is set up to cover six different issues as listed on the agenda. So here's a couple housekeeping notes. The agenda is available online on our committee's website, and physical copies are available in the hearing room. You can also find available online several supplemental publications provided by either the LAO or stakeholders.

At the end of each panel presentation, we'll take questions from members followed by public comment. And as a reminder, public comments will be taken in person at the end of each issue. We ask that you keep your public comment to a name, position on the issue, and organization. So, again, we have six topics.

We have 40 technical, and other witnesses that are gonna be presenting, and so we just ask that the public is also respectful of one another in terms of the time at the mic as we'd like to, allow people access to what is happening and be fully transparent in our budget process, but also move expediently so that no one feels they have to miss out because time is getting too long.

If you're unable to attend in person, you may submit written comments via email to [email protected]. And at the very end, we will open public comment for items not on the agenda. So we're gonna begin now with oversight. No. This yeah.

With oversight of reproductive health, state investments. This issue and please come on up to the table as I'm talking if you're here for this, witness for this panel. This issue will examine the five reproductive health programs established by the California Department of Health Care Access and Information in response to the Dobbs decision and the ongoing uncertainty surrounding the federal title 10 family planning program as well as our state's response to HR 1's targeted defunding of planned parenthood.

For this panel, we welcome to the witness table director Landsberg from the California Department of Health Care Access and Information, Kelly Mossberg on behalf of Essential Access Health, and Nicole Barnett, president and CEO of Planned Parenthood NorCal, and then we also have the, LAO. But we're gonna begin with the with HCAI director Landsberg who will provide a brief overview of the five HCAI reproductive health programs, their current status, and funding outlook.

And as each of you goes on to, testify, if you could please introduce introduce yourself before beginning your testimony, and, please start when you're ready, director Landsberg.

Thank you. Good afternoon, madam chair and members. Elizabeth Landsberg with HCAI, the Department of Health Care Access and Information. Pleased to be here to discuss the reproductive access programs that we have administered at HCAI. So the twenty twenty two, twenty three budget included five programs with a total of a 120,000,000 appropriated for HCAI to implement to ensure access to reproductive health care services including abortion.

The first is the uncompensated care grant program, which allocated $40,000,000 for health care providers who deliver abortion and contraceptive care to individuals with income up to 400% of the federal poverty level who don't otherwise have coverage for these services. And HCAI partnered with Essential Access Health to administer the programs and distribute funds to providers. 39 grantees have been funded over the past three years, and they have served almost 200,000 eligible patients in all 58 counties.

The second program is the abortion practical support fund, which provided $20,000,000 for services that support access to abortion care, including transportation, lodging, meals, abortion care doulas, and child care and elder care. The program also supports organizations in building and expanding capacity to live to deliver these services.

So, again, with this program, we partnered with Essential Health Access to distribute funds. More than $11,000,000 have been awarded of the original 20,000,000 to 45 grantees over the past three years, and there is a remaining balance of of a little over 8,000,000 and a fourth cycle running starting this July. We do anticipate all funds will be expended during this cycle.

The third program is the capital infrastructure program aiming to enhance the physical and digital security infrastructure for health care facilities and reproductive health practitioners who provide abortion related care. And here, we awarded to 36 grantees.

And, again, this was both cybersecurity and physical security for these facilities. Fourth was the clinical infrastructure program, $20,000,000. And here we have the scholarship and loan repayment programs where we provided scholarship and loan repayment to professionals who commit to providing abortion related and reproductive health services in underserved areas of California. So we've awarded scholarships and loan repayment to 342 Clinicians, including physicians, nurse practitioners, PAs, midwives, and nurses. The other piece of this program was the reproductive health hotline.

So we launched a free confidential clinician to clinician consultation hotline, partnering with UCSF to provide, support services, consultation calls on topics such as STIs, contraceptive, contraception, abortion, and abnormal uterine bleeding. And then fifth was the reproductive health services core established to recruit, train, retain, and support a diverse workforce of health care professionals to commit who commit to providing reproductive health services including abortion care.

So here, we partnered with two different entities, teach, the training in early abortion for comprehensive health care, was one entity, and then birth control pharmacist was the other entity. I know that there's a timeline, so I'm happy to go into additional detail about either those five programs or the additional, funds that HCAI has administered through, Prop 35 or otherwise is interested.

Okay. Chair members, Kathy Mossberg on behalf of Essential Access Health. For more than fifty years, Essential Access Health has served as California's title 10 federal family planning program grantee, and we have been supporting a statewide network of providers delivering high quality affordable reproductive health care. I wanna begin by thanking expressing our appreciation and thanking this subcommittee and the legislature as a whole for all their efforts in the reproductive health space, and we every day see the positive impacts of this of this fund.

We've been asked today to address a couple of issues.

One, the current the current need and situation with uncompensated grant program and to provide a title 10 update. First, wanna start with uncompensated care grant program. Essential access as noted here by the director of HCAI was, is currently the administrator of this program. We actually are the administrator of three programs created by this legislature to protect access to abortion and contraceptive post Roe. Together, the LA safe haven pilot program, practical support, and the Uncompensated Care Abortion Access Program have served more than 230,000 people.

Wanna highlight the Uncompensated Care Program, as again noted here by the director of HCAI, we have 39 grantees receiving $40,000,000 to deliver abortion and contraceptive services to approximately 200,000 patients, ninety percent whom are California residents across every county through both in person visits and telehealth. At this point, all the funds in this, in this grant program have been awarded. So without renewal, this program will be eliminated. Our grantees stress that this funding is a lifeline for under underserved areas, and its continuation is absolutely critical.

They fear being forced to turn away those unable to pay.

And because, we we can go into greater detail at another time, but we certainly have examples of the care provided to individuals and how they're able to, through this through these dollars, gets get services they normally would not otherwise be able to get. Because of HR 1 and because of lack of federal funding in various places, we know at this time the need is rising, not diminishing. We can't afford to lose this critical safety net.

So we have, along with our champion, Assemblymember Bonta, thank you, recognized the state's budget realities, but we have put forward a budget request of $10,000,000 to be spent each year over three years for a total of 30,000,000. We believe there's a potential to combine both general fund dollars as well as other resources included in the new abortion access fund that was created last year.

Other states have established similar programs post Roe and have maintained them. California has always led, and this is certainly not a moment to back away. We respectfully urge you to sustain this program. And then moving on to title 10, as you know, last year, the Trump administration unlawfully withheld title 10 funding for several months. The consequences were immediate and severe.

Staff positions were cut. Case work care workforce was diminished across the state. This legislature stepped in to provide $15,000,000 in backfill. And though that investment stabilized the network, ensured continued access to essential time sensitive services, like birth control, STD prevention, and treatment, cancer screenings included. Because of that action, the title ten network was sustained, and we were able to see 500,000 patients in California last year.

But federal, uncertainty remains. We have just received the notice of award this past Friday for California. It is at level funds. So it is at that 12.5 level. This is delayed though, and we're we're in a similar situation where we would have normally, under different circumstances, we would have been ready to go.

We would have been working with providers. We normally get the information far earlier than what we're getting it now. But because we have these $15,000,000 funds, we've been able to use them and actually start to build up and and provide dollars and backfill dollars to provide stability to all the title 10 providers across the state. So we, again, really wanna thank you, and we will continue to keep this committee updated.

We are expecting potentially some language to be tied to those federal funds that could make it difficult to use, broad based in the community.

But at this point, we do not have that detail. We will keep this in in this committee and staff informed on that. With that said, wanna thank you for your time and happy to answer questions.

Good afternoon. Madam chair and members of the committee, my name is doctor Nicole Barnett. I'm the president and CEO of Planned Parenthood Northern California, where I oversee operations of 17 health centers spanning from San Francisco all the way to the most northern rural counties of our state. I'm here on behalf of my own affiliate, but also as well as the six other planned parent planned parenthood affiliates serving the state of California. Since 07/04/2025, planned parenthood has been blocked from receiving federal Medicaid funding under HR 1.

The intent was clear to defund Planned Parenthood, force health center closures, and restrict access to essential care. Since its inception, this defund has had real consequences. Nationwide, 23 health centers have closed, including five right here in the state of California. This impact is especially significant here in our state. Collectively, our affiliates serve one third of all Planned Parenthood patients nationwide, with over eighty percent of those patients relying on Medi Cal and Family PACT.

Planned Parenthood is the largest provider in both programs delivering critical services like birth control, STI testing, cancer screenings, not abortion services which remain state funded. The defund threatened over $400,000,000 in care for low income Californians. We are incredibly grateful to this legislature and to the governor for doubling down as a reproductive freedom state and helping us to weather this devastating defund. California stepped up to use state funds to keep Planned Parenthood health centers open and to ensure minimal disruption for our patients.

However, this stability is temporary.

The defund expires on July 3. And if it ends, we may resume normal medical operations and the state will be able to pay family planning claims using federal matching funds. However, if the defund is extended, we will once again need to explore alternative funding mechanisms or else we face devastating cuts, which will impact access for patients enrolled in Medi Cal programs. Despite these challenges, we continue to serve. Programs like the uncompensated care fund have been absolutely critical.

At Planned Parenthood Northern California alone, we served nearly 7,000 patients last year in five languages through this program. Of the hundreds of patient stories that I could share with you, there is always this common theme. Patients come to us because they know they will be treated with dignity, with respect, and without judgment. And we are honored to be that provider. And we strongly support the budget request for $30,000,000 to extend its operation for another three years so that no patient is turned away.

Thank you again for the opportunity to speak today. Planned Parenthood remains rooted on our mission to provide care no matter what. Thank you.

Anything from the LAO to add? Thank you. Any member comments or questions? Yep. Please, Assemblymember Bonta.

Thank you. I wanted to just address the uncompensated care needs. Given the fact that it sounds like we will the the demand has not waned at all. Given the changes to medical, we also know that there will be more people who will be dealing with an affordability gap. With this in mind, has essential access seen over seen any year over year unmet needs in the program?

Yes. We have. And we can get you the specific numbers on that, but we have definitely seen over subscription of about 2 to $3,000,000 every year to the degree that we've been able to keep track of that. We assume there's probably larger than that, but that's that's what our numbers are showing. That while these funds are helpful, there's certainly still need out there.

Yeah.

And then I know that we've been able to have an opportunity to continue to fund and fill the gap for Planned Parenthood. Are you foreseeing what are you what is the future foreseeing for Planned Parenthood and being able to cover ensure coverage. I always am struck by the fact that 22,000 people a week, is it, go through Planned Parenthood doors?

Depending on the affiliate that you're speaking of, it's patients who continue to come to our doors for care. But because of the federal defund, we've lost access to the federal funding. So the funding and the assistance to the state has been essential for us to maintain access to care.

Like I mentioned before, if the federal defund is extended, it means that we will continue to be prohibited from access to federal funding, and it means that we will have to seek alternative resources in partnership with the state to continue to keep our doors open.

Thank you.

And then my last question, sir. The to HCAI, given that these five programs that were established for one time funds, many of them have been fully expended, have you been able to do an analysis around the efficacy of the five programs or where you believe that we are going to need additional investments across these five programs?

We have been collecting data from our partners on the essential access, and we shared some of those, and and they're included in the agenda. I would note that the reproductive health services core, those training programs, and the residency program and the pharmacist, those are ongoing programs through 2028. We as noted, we still have funds for the practical support, but the governor's budget does not include additional funds for the uncompensated care.

Okay.

Thank you.

Assembly member Patterson.

Great. Thank you. Questions about the, uncompensated care program. So my understanding is, health plans in California, unless they're self insured, are required to cover, abortion services. Is that correct?

Correct. So this money is going to individuals who are mainly self insured or they receive their insurance through a self insured health plan or what what's the uncompensated paying for?

So the uncompensated care program covers for folks who do not have coverage for abortion, including uninsured people who are uninsured.

So those individuals oh, six to eight percent of California's population is uninsured. So so for that population?

Again, the the parameters of the program are to provide services for people who do not otherwise have Coverage. I don't know if there's anything, miss Mossberg wants to add.

Yeah. I mean, I would just say we are seeing plenty of folks come in who don't have access to insurance and are under the 400% of FPL. I think it depends on certainly year over year what the demo what that demographic will look like. We're certainly starting to see more. You've got people being pushed off medical.

You've got people not having access to covered cal, and then you've got the federal ban in certain ways. And so we've mainly seen Californians in this program as I noted. So 90%.

Yeah. I mean, it would obviously, if we're spending $40,000,000 a year, it would just be interesting to know where that gap in coverage is.

We we

would notice 40,000,000 total expended over three years.

Okay.

Yes.

$13,300,000 a year on average. Yeah. Just would be interesting to know where that gap is. I don't think I'd be the only one interested to to know in that. And do we know why approximately forty nine percent of abortions in California are performed for individuals on Medi Cal?

Is there a pattern or a demographic or some kind of pattern about why that's the case?

Yeah. Not that I'm aware of. I don't have that statistics for you.

Okay. And that wasn't some statistics I just pulled up. I mean, that was from the unit UCSF. That was a a number from UCSF. The advancing new standards in reproductive health.

So it wasn't some blog I got it from or something like that. Just seemed like a really high number that a percentage of the population of individuals getting abortions are on Medi Cal.

Oh, I guess in Contontorro Celio. So I I'm not familiar with that statistic and and haven't looked into it too deeply, but I would just emphasize that in Medi Cal, some populations are disproportionately in Medi Cal because of different income thresholds, and particularly, children and pregnant persons are are populations that have higher income thresholds. This is because we have CHIP as part of our Medi Cal program. And so that that, that those populations tend to be at higher levels.

So that could be one reason why you're you're seeing a disproportionate amount of abortion, coverage in Medi Cal.

There could be other reasons too, but just wanted to note that as one possible, one possible reason.

Yeah. Well, how many people are on Medi Cal? How many Californians?

It's, like, 14,000,000 or so. It's a it's about a third of the state, but it's, like, half of kids. Yeah. And then at for pregnant persons, I I don't know what the participation rate would be. But it does it does vary quite a bit depending on the

So third of the state, but half half the abortions roughly, if that statistic is correct.

And as mister Konstantinos noted, there is a higher income threshold for for pregnant people on on medical. Okay. So you have more than a third of the pregnant population that would be on Medi Cal.

Yeah.

Okay.

Question for Planned Parenthood, and and thanks for your time. I honestly not overly familiar with too many of your services outside of abortion. And so I was wondering if you could help me understand if you get funding for and and how much services you do to help women who are opting to keep their babies and need maternal care.

Absolutely. So we do pregnancy counseling. If the individual decides that they do want to continue that pregnancy, we can refer them for prenatal counseling. We can refer them for prenatal care. They can also return to us for women's health care post having their baby as well.

But when they're pregnant, you don't provide in in house counseling or services or continued ultrasounds or or things like that?

No. Not currently in my affiliate. We don't have those resources to provide those services, but we do refer.

Okay. I mean, Medi Cal would cover those as well, I would assume. Right? So seems to me it might be a worthwhile venture to provide those services if Medi Cal is gonna pay that bill. I mean, it might be a way to keep your doors open, to continue to pay the providers that are working there, that you provide services and ultrasounds, which are critical for the Medi Cal population as well, who are lacking maternal care, and it's hard to find that care in California.

And actually, we've heard that in that there's these hearings alone, and we underfunded that in California. And we should maybe increase funding around that, and I think my colleagues would support that. But but it does seem like maybe a way you keep those ultrasounds moving, you know, during this budget crunch

If you will. So

Yes.

So in the past, we did provide, prenatal care, but due to the reimbursement rates, we weren't able to continue that. So, it's helpful to hear you say that maybe if the reimbursements rate were more appropriate that we could take that on again. We certainly wanna stand to support.

I mean, I would love to increase reimbursement rates for maternal care. We spend a lot of time funding and and finding all sorts of money to fund abortion care. And I think maternal care, all of us have been beneficiaries of maternal care, hopefully, and, you know, otherwise, probably wouldn't be here. But but, yeah, I I agree. We should increase reimbursements for maternal care 100%.

So thank you very much.

Alright. I I think all of my questions really have been asked by folks on the dias. So we are gonna open up to public comment. So this is our item on reproductive care. If there's anybody in the audience that wants to speak to oversight of reproductive health state investments.

You're welcome to come up to the mic and, name organization and position. We're just gonna check the hallway.

Hi. I'm here to support the uncompensated care fund. I'm from teach. My name is Bethany Golden. I'm a nurse midwife as well as the co director of the Reproductive Health Service Core. Thank you very much for your time. Thank you.

Good afternoon, Karen, members. Karen Stout here on behalf of the California Nurse Midwives Association. We just wanted to express where, gratitude for you convening the hearing. We're pre reproductive health care providers, including abortion care providers. We support continued investments and strongly encourage you to preserve, the sanctity of the state's abortion care. Thank you.

Hi. Thank you all so much for your time. I'm Madeline Merwin. I'm a resident physician, and I'm here representing the Bixby Center for Global Reproductive Health. You've raised some amazing points today, so many of which we rely on expanded Medicaid coverage for reproductive services for the patients that we do advocacy work and research for.

There is a plethora of data that shows our state has proud reproductive health standards, and we have proud reproductive health outcomes because of the care that we can provide, including abortion and expensive reproductive care. So please consider continuing that and continuing that legacy so that providers can continue giving the care that our patients deserve. Thank you.

Okay. Seeing no other public comment, we're gonna move on to issue three on our agenda. Issue three on our on our agenda, long term care services and supports. And if you're a witness, please come up while I'm speaking.

This issue examines three specific issues within California's community based long term care the status of wait lists for the home and community based alternatives or HCBA and assisted living waiver programs, ALW, the transition of congregate living health facilities or or CHLF into managed care and the status of the moratorium enacted on the program for all inclusive care for the elderly or pace.

Due to the limited space at the witness table, we may take each issue as a sub panel. So we'll start with HCBA and assisted living waivers, and we've got DHCS that will provide a brief overview of the current status of both waiver programs with a focus on slot availability and current wait lists, and then, we will move on. And if you could please introduce yourself before you provide testimony, and feel free to begin when you're ready. Welcome.

Good afternoon, chair members. Michelle Baass, director of the Department of Health Care Services. The home and community based alternative waiver and the assisted living waiver are both home and community based waiver programs developed to create alternatives for individuals who would otherwise, receive care in a skilled nursing facility or hospital. These waivers allow, services to be offered either in a home or a community based setting.

The services offer an offered under the waiver must be cost neutral or cost no more than the alternative of institutional level of care.

Both of these programs operate under enrollment caps or slot limitations. In response to the committee's, questions in the agenda, I'll share some of the numbers, and these are, as of 04/01/2026. So with regard to, the total authorized enrollment slots, under the HCBA waiver, we have 14,374, for the assisted living waiver, 18,144. Total enrolled participants, for HCBA, a little over 11,000, and then for the a ALW waiver, 14,579. Both of these programs have waitlist.

As as I mentioned at the beginning, these programs operate under enrollment caps. The total wait list for the HCBA waiver is 6,145, and for the assisted living waiver, 16,130. The average wait times from a waiver application to enrollment varies. There are different referral pathways for each of these waivers, and so the the the wait times vary depending on the referral pathway. For, the HCBA program, it's twenty five days.

And then for the ALW program, currently, we do not track, the average time from the ALW application to submission to enrollment. We are actively working to develop such a system. The HCBA waiver has a five year term and enter into a waiver year four on 01/01/2026. 1,800 slots were added to the waiver effective January, increasing the maximum capacity to 14,374 enrolled participants. And an additional 1,800 slots will be added in January 2027, bringing the total under this, this term of the waiver to 16,174.

We are working with our waiver agencies to address increasing efficiencies in the enrollment processes, but key constraints in terms of increasing capacities for both of these waivers is workforce and staffing. And workforce constraints really bring being the primary driver for direct care workforce such as private duty nursing, nurse providers, personal care agencies, etcetera. Happy to answer any questions.

Thank you. We're gonna so we're taking just to tell the committee what we're doing. We're taking each issue for this panel separately, seeing if there's committee questions, and then we will go on to the next issue, see if there's committee questions, go on to the third issue, see if there's committee questions. At the very end of all of that, we will take, public comment on issue three, which is long term care services and supports overall. We also do have DOF and LAO here.

Anything, that you'd like to add from LAO or DOF?

Good afternoon. Karina Hendren, legislative analyst office. Regarding the HCBA and assisted living waiver wait list, we wanted to first note that the legislature does have the ability to direct the administration to increase the number of slots in the waiver. But that being said, whether increasing the number of slots would actually increase access to the services is uncertain. This is in part because the slot increase would be subject to federal approval, and any increase in slots would be conditioned upon meeting federal cost neutrality rules.

Additionally, as the agenda notes and as director Boss noted, there can be capacity issues among waiver agencies or providers, and this means that increasing the number of slots on its own would not necessarily increase access to waiver services. Due to this, there may be additional programmatic changes that might be needed to increase the number of people enrolled in these programs.

Thank you. So for, this item on the HCBS and ALW, are there any questions from members on the dais? Assembly member Bonta.

Thank you. As you know, I have several HBCA waiver providers, participants in my district who've, we've been working with over time. I just wanted to kind of note that it is a significant opportunity for cost savings and and an ability to make sure that we are providing care for extremely medically complex patients.

Given LAO's comments about the capacity, I I actually wanna learn learn more about that because I my understanding is that there is capacity that is being underutilized by several providers and wanted to just get a sense of from director Boss what the plan could be going forward to ensure that we're integrating more community based services through HCBS programs into managed care?

So we're not necessarily tracking that there's capacity that's not being made available or is not available. So we're happy to engage if you have providers who say they have capacity. That's one of the topics that we have for the congregate health living facilities where it is a waiver program that we are proposing. It's the next item to turn that into a managed care benefit. So that can be more broad and not be limited to caps or slots.

But with regards to the other HCBA or assisted living waiver, not tracking the excess capacity that isn't isn't being used today

I don't know.

That's a good question.

She's gonna respond.

Did you respond to the question. Yeah. Please. Yeah.

Just to note in response to Assemblymember Bonta, there is a wait list. The programs do have wait list. And so in that sense, not everyone on the wait list is currently making served, and that's correct.

So that that was your point that there's there are wait lists

Yes.

And there's not enough ability for us to be able to provide the care.

Correct. Okay. But kind of the the point we were trying to make is that bringing those wait list number down and getting people actually enrolled in the program, part of the equation is just the slots themselves. But then the other part of the equation is making sure that there are providers who can actually serve those people once they're brought off the wait list. So there's the workforce kind of component of it as well.

Okay. Alright.

Assembly member Schiavo.

Just so just so I'm clear. Are we tracking whether or not there is capacity that is not being utilized or we're not tracking that? Or we know everybody's at capacity and there's no more space?

That's why we have the the wait list because we have individuals who can't get into a certain facility a member agency. And so if there are providers that are are we on the congregate health living facility, which is the the next item, tracking that there is excess capacity potentially available, which is why we're proposing to transition that particular agency into a different benefit so that it is more available.

Okay. So so we are at maximum capacity is what you're saying. Right. Maxed out

Which is why we have wait list in terms of the existing waiver agencies that we have today or those that can be, you know, potentially brought online. There is processing of those applications, but we are tracking. We we have a wait list.

So what is so explain the difference between the wait list and the slots. What's a slot?

The slot is just an informal term for the number of spots in the waiver. So the way I can't remember off the top of my head how many slots there are, but it's a number of people who can enroll in the waiver at a given time. And then the wait list happened once all the people once all the slots in the waiver are full.

Okay. Yeah. So but even if there were more slots, there's not more capacity.

If we were to add slots, we could create more capacity, but this is where the workforce and the ability to actually create it's it's a matter of having more nurses, more kind of providers to be able to provide these services. And so it's it's it's to to the LAO's point, just if we add slots doesn't necessarily mean that we will be increasing capacity.

Can I just ask a follow-up on that? So how I get the basic concept that we need more people in the workforce to be able to, if we were to open up those slots. Can you just do a comparative, just a rough comparison around the cost of care to somebody who is in a skilled nursing facility compared to somebody who is able to receive the care through HCA waiver services. So just where it makes the most sense for us to be able to invest our dollar.

So the the cost for these waiver programs have to be it has to be cost neutral or less. And so I don't have the exact number of, you know, the comparison of a of a waiver slot versus a skilled nursing facility stay, but it has to be that no no greater. So that's why we are we want to expand these and grow these because they are more cost effective and individuals are served in their home or in in the community. This is our goal.

And that's why we've been adding slots 1,800 or so for the different programs over the last few years, growing the capacity.

But clearly, you know, individuals want this to grow even faster than than we have proposed.

Is it possible that you have that we have not paced our increase in the number of slots accordingly. So if you said 1,600 new slots?

1,800 for one of the programs and yeah. I can find it. But yeah. 1,800 slots for HCBA over the last few years, And then I believe it's 1,600. I can get that.

But we have a wait list of 6145 on HCBA and 16,130?

Wait list. Yes. Yeah. 6,145 on HCBA, 16,130 on the assisted living.

Right. So is it possible that we perhaps should consider increasing the number of slots perhaps at a bit higher of a level than we have in the past?

These are the things that we've been working through and kind of again, it's to the point of we can increase the slots, but they may not be able to be staffed. And so trying to find the balance of where we think we are actually being able to increase capacity and provide true access versus a slot that is meaningless because there's no, you know, no ...of nursing or whatever it may be that needs to staff.

How how are you determining whether or not you can actually have the workforce? What are what's the quantifiable data that you are using to determine So and project the workforce associated with that?

Based on conversations with our waiver agencies and kind of just the field and what is available and what they think they can bring up. I don't think we have a quantified way to do that, but it is based on these conversations and the ability to process the applications, and the time it takes to do that.

Okay. I I think given the, clearly, the pretty extensive wait lists, it might be helpful if we get a little bit more granular and rely less on anecdotal information and more what the particular drivers are for either the workforce or whatever the other kind of friction points are in the increase given the fact that this is a cost neutral, and in fact potentially cost savings opportunity for for the state of California. Just hope that we get a little bit more specific about it.

Assemblymember Patterson.

Great. Thanks. In terms of the slots, so the slots require a federal waiver? Correct. And is the are the are those, like, routine things or we gotta grovel for them?

Like, how does that how does that work?

Sure. I would say it's somewhere in between. So these are less policy sensitive, and they're they're more routine insofar as when states are able to meet sort of applicable federal authority requirements, you know, nineteen fifteen c waiver requirements. Director Boss mentioned sort of budget neutrality being chief among them. We're able to demonstrate that any proposed increase in slots meets the federal requirements we ordinarily would expect federal approval.

Typically, this happens sort of on a year by year basis. So based on the waiver year, we propose increased slots on a on a year basis. It takes, you know, months to go through that process, but we don't have to grovel if it complies.

Yeah. And I noticed in the original well, I think my memory serves the original congressional letter that I brought up last time that I think you've since responded to, they had mentioned IHSS. Didn't really provide any information at the time, but generally speaking, had mentioned, you know, Minnesota IHSS is a area in which there's more prone to be fraud. That was a statement, I think, in that letter.

Is there in terms of getting these waivers, does does that kind of thing come up, in those discussions about how the state's checking for fraud?

Or I'm just wondering in terms of the the federal checks and balances on that, how that plays in, if at all, to these particular slots.

So in an ordinary environment, that wouldn't come up as a targeted question. I think at this point in time, we wouldn't be surprised to receive that type of question from CMS given the letter from doctor Oz that was sent to our department regarding IHSS and growth in IHSS in particular.

We are starting to hear anecdotally that other types of waivers that are more sensitive, such as eleven fifteen demonstration waivers, The Federal Government is starting to propose new terms or, conditions in the waivers related to sort of general program integrity safeguards, not specific to any given state. We haven't seen that occur yet in these type of nineteen fifteen c waivers.

Yeah. Okay. Great. Yeah. I mean, I I think, you know, I mean, I've everybody's consistently supported, you know, IHSS, you know, in this building.

And I think it's important, you know, component. Obviously, I just wanna make sure we do our part, not not that we're doing anything different, but to, like, mess that up. Right? Because it is pretty important to a lot of people. Last question on long term care, just generally speaking, because I had recently met with a constituent who unfortunately husband has to go into long term care, and she had mentioned something about awaiting some kind of federal approval or something for that.

But is this a state is there a separate federal long term care program, or is that administered by the state long term care just generally administered by the state?

So it depends on their source of health care coverage. And if it's Medi Cal, by long term care, if it's, like, a skilled nursing facility or sub acute facility, we operate that in compliance with sort of federally approved authorities. Those facilities are also sort of regulated and certified according to federal requirements.

If by long term care, maybe they're referring to, like, an assisted living facility that would be covered under this waiver, it would be subject to the types of caps that we're talking about on an enrollment here.

Alright. Well, last thing, just in case we're switching topics, just wanted to thank the department. I know we've been working on an issue totally unrelated to this for many years now. Haven't quite got there, but I do appreciate, you know, the back and forth. And I think we're going to get there one way or another, and I know we're all committed to it.

So thank you very much for working with me on that.

Back onto the cost of the kind of the cost differential between skilled nursing facilities and the cost of waiver services. So the and this is for DOF.

Oh, thank you. So I I believe that the the cost of one year of skilled nursing facility care is a $110,000 on average.

The DHCS is quoted in the past compared to $24,000 for waiver services for these really medically complex individuals. Do you all believe that it makes more sense to try to ensure that we are maximizing our HCBS waivers to ensure that we are recognizing more cost savings?

Natalie Griswold, Department of Finance. I think we would point to DHCS's comments earlier that the number of HCBS slots has expanded in the last several years, and we're kind of looking at the number of slots that can be, you know, staffed up so that they can support those needs.

However, the the people the number of slots has expanded. Presumably, those people would be in skilled nursing facilities that cost considerably more.

Yeah. I think yeah.

Right. So so the number of people that we are trying to get into the lower cost service, Ie the waivers for at $24,000 is seems to make a lot more financial sense than keeping people in skilled nursing facilities at a $110,000, per year. Just from a pure math perspective, that seems to make a lot of sense. Would you agree with that, Beth?

Yeah. I think that we, you know, we understand that the HCBA waiver slots are, like doctor Boss said, they have to be budget neutral. We understand that this have this can reduce cost in other areas. I think we understand that.

They have they have to be budget neutral or less. The point that I'm trying to make is that they are significantly less. Is that based on the numbers that we have in terms of the cost of those services? Is that accurate that they are significantly less?

That the cost of HCBA waiver slots is less than the cost of long term care slots. Yes. I believe that's accurate.

$24,000 versus a $110,000. Okay. Okay. So given that fact pattern, what can we do to make sure that we are and I heard director Baass talk about the need to make sure that we are increasing the workforce.

What can we do to make sure that we are providing the cost savings that comes with ensuring that we are increasing the number of waiver slots? What are some direct steps that we can take to make sure that we are saving 75 to $85,000 per patient? I guess that's a question for DHCS.

I think addressing workforce challenges which we have across the street across the state, you know, all the health care industry and sectors, private duty nursing, for example, very difficult to find those providers. And so figuring out how to address the workforce challenges is is one of the key areas. And I know there have been many discussions on in that space for how do we attract more nurses, for example, how do we build out that workforce.

But I think that is gonna be the key issue in terms of being able to increase capacity.

Thank you.

Seeing no other questions from the committee, we are actually gonna recess our, sub one regular hearing, and we are gonna move into our joint hearing with Senate budget subcommittee number three on health and human services. So we welcome Senator Menjivar and committee members from the Senate budget subcommittee number three. And this is issue number one on your agenda, which is access to gender affirming care in California.

Good afternoon. This is a very warm and small committee room. It's it's It's on. It's on. Oh, no. That's a lot. Assemblymember.

Welcome to the joint subcommittee Senate subcommittee number three and assembly subcommittee number one on gender affirming care today. We I we are gonna be mindful. I know the assembly has a lot more issues to talk about in their sub one, but we were gonna be give our due diligence to this topic. I wanna thank my fellow chairs and member Don Addis here in the subcommittee members. As you can tell, I'm riding solo.

They usually have it goes on the Senate side. I usually ride solo, but hopefully my colleagues would join me on this one. Since the very beginning two years ago, the the Trump administration has meticulously, inhumanely attacked the LGBTQ plus community, specifically the trans community, even though it is point 003% of the entire population.

There's only about 2,000,000 trans individuals in the entire United States, with California having about 240,000 of them, the most in the whole, country, which is why we're front and center because we believe that everyone deserves the right to be treated equally and fairly. And even though the federal administration has attempted time and time again, I'm very thankful for our attorney general who has time and time again responded with legal action in putting putting halts to a lot of them.

And while we're still waiting on some of those final rules, we will continue to fight fight back. But what we've seen so far is that we've we've won most of, the legal actions and have been able to hold the the the Kennedy declaration or other issues that have come forward.

So today, we're gonna talk about what is reality for the trans individuals in California, what more can California do, where are the gaps that exist, and is us putting funding like we did last year of the 15,000,000 enough? Is it being utilized? And like like I said, what more can we do? Madam co chair? Fellow chair?

Thank you, Senator Menjivar, madam chair. I really appreciate, and it's a privilege to be able to join the Senate budget subcommittee on health and human human services for this particular hearing. I know that our subcommittees jointly touched the lives of many, many Californians, and our work together really is a testament to how important this issue is both to the assembly and the state Senate.

And we know that California is home to a very a large, although albeit very tiny yet large compared to other populations in the nation of transgender, gender diverse, and intersex populations, and that the research is clear and evidence is overwhelming that gender gender affirming care access to gender affirming care is not just medically necessary and life saving, but it's also supported by every major medical association in The United States.

And for youth in particular, gender affirming care is associated with a sixty percent reduction to moderate and severe depression and a seventy three percent reduction in self harm or suicidal thought amongst transgender youth.

And so I think today's hearing is particularly important. I also know just from some of the things that are going on outside the room that there's a lot of passion from some folks on this issue, and I just wanna make a personal request that regardless of someone's opinions or their level of passion around this issue that they present with decorum when you come to the mic for public comment. We ask for decorum for kindness, for respect, even when you hear opinions that don't match your own.

And so I'd also like to personally thank our partners from the Department of Justice, Department of Managed Health Care, Department of Health Care Services, and most importantly, the part the parents, the families, and the, patients, the children at times behind every policy and budget discussion that we have, there's a human face and there's a human effect.

And and I think it's very important that we pull ourselves out of the headlines, pull ourselves out of the politicization, out of the politics, out of the social media conversations, and just be in the room together, human to human, and understand that what we're trying to do in the charge of this budget subcommittee is to look at how are we funding health care for 40,000,000 Californians, some of whom happen to be gender diverse, transgender intersex.

And so we have a, a very serious responsibility here in this room, but we should be doing that, taking care of that responsibility with kindness, with respect, and with decorum. And we just ask that anybody who's participating in this discussion today show the same. And so thank you again, Senator Menjivar, for your leadership, for your partnership, for welcoming us to join you, and I look forward to this discussion.

Alright. Let's get into it with our first panel. It's gonna be a legal landscape and access to gender affirming care. We're joined by the Department of Justice, Department of Managed Healthcare, and Department of Healthcare Services. I'll have DOJ kick us off.

Good afternoon, honorable members. It's a pleasure, and thank you for the invitation. I'm Neli Palmer. I'm the senior assistant attorney general for the health care rights and access section. This is the section that leads on the attorney general's affirmative health care matters.

This includes civil rights and health equity, consumer protection, reproductive justice, tobacco enforcement, and fair competition. In the civil rights and health equity arena, this includes ensuring access to health care for LGBTQ plus community. This includes, of course, gender affirming care. I would like to pass to deputy attorney general, Crystal Adams, who is our lead on, several of our matters involving gender affirming care, and she can walk through, the efforts of the attorney general to, address these issues.

Thank you. Distinguished members of the committee, good afternoon. Thank you for the opportunity to present today. Attorney General Bonta is committed to upholding state law and ensuring Californians can access medically necessary health care. California law protects access to gender affirming care in a variety of ways.

I will summarize some of those protections here, and I will then turn to some of the legal actions that our office has taken to defend against attacks on this care, patients, and providers. In California, health care providers and insurers covered by state law cannot discriminate against the patient for being any of the following, transgender, a person diagnosed with gender dysphoria, non binary, gender nonconforming, or intersex.

Insurers and health care plans covered by state law are prohibited from denying an individual a plan contract, a health insurance policy, or coverage for a benefit included in the contract or policy based on a person's gender identity. State privacy laws prohibit health care providers, health plans, and insurance companies from sharing patients' personal health information with anyone except in limited circumstances. And California's shield laws protect patients and families accessing gender affirming care in our state from other states' investigations and attempted civil or criminal prosecutions.

California employees, contractors, and agents may not aid another state's investigation of an individual for accessing gender affirming care or helping someone else access that care if that care is lawful in California and performed in California. Attorney General Bonta has taken many significant steps to combat the Trump administration's campaign to end gender affirming care nationwide. Our office is currently litigating several lawsuits that challenge the Trump administration's attacks on this care.

First, on 08/01/2025, we co led the filing of a multistate lawsuit challenging executive order fourteen one eight seven, which we refer to as the denial of care executive order. And we also challenged the US Department of Justice's attempts to implement that order.

These actions threaten civil and criminal prosecution against providers of gender affirming care in an attempt to intimidate those providers into stopping care. The parties in this lawsuit have fully briefed the government's motion to dismiss the case, and we are waiting for the court to schedule a hearing or just rule on the papers of that motion.

On 12/23/2025, we joined a multi state lawsuit challenging US Department of Health and Human Services secretary Robert F Kennedy junior's declaration that claims gender affirming care fails to meet professionally recognized standards of care. And as such, HHS may disqualify any doctors or hospitals that provide such care from Medicaid and Medicare. On March 19, the district court ruled from the the bench and granted our summary judgment motion and held that it will vacate the Kennedy declaration and issue declaratory relief.

The court is still considering whether to issue a permanent injunction that would prohibit HHS from attempting to subvert the court's order by excluding providers from Medicare and Medicaid based on a policy that is substantially similar to the Kennedy declaration. We're awaiting the court's decision on that. And finally, after Ratey Children's Health announced in January its decision to end gender affirming care for all of its patients, we sued to protect access to that care.

The court has issued a temporary restraining order in that case, which requires Rady to continue providing medically necessary Jennifer gender affirming care to those patients. Our preliminary injunction motion hearing is set for April 27.

In addition, when hospitals have tried to resist the Trump administration's attacks, the attorney general has joined a multistate coalition to file amicus briefs supporting those hospitals.

To date, we have filed multiple amicus briefs in favor of hospitals seeking to quash the Trump administration's invasive subpoenas demanding private patient medical records, and we have filed amicus briefs supporting reputable scientific and medical professional associations like the American Academy of Pediatrics, which the Trump administration is improperly targeting in an attempt to intimidate and deter them from recommending evidence based health care.

In addition to all of this, we have also filed multiple we've submitted multiple public comments opposing the administration's proposed rules that will that are seeking to substantially restrict access to gender affirming care. In particular, we submitted a comment letter opposing the Medicaid reimbursement rule, which would prohibit the federal Medicaid program from funding gender affirming care for patients under the age of 18 and would prohibit the federal children's health insurance program or CHIP from funding gender affirming care for patients 19.

We also submitted a public letter opposing the conditions of participation rule, which would prohibit medical providers who provide gender affirming care to patients 19 from participating in Medicaid and Medicare.

So it's very similar to what the Kennedy declaration would do. If that proposed rule goes into effect, every patient, regardless if they receive Medicaid or not, 19 at a hospital would lose access to gender affirming care because hospitals cannot financially sustain themselves without Medicaid or Medicare funding. And our office is ready to fight to prevent those rules from going into effect. And with that, I'll pause and see if you have any questions. Thank you.

We'll we'll go through the panelists, and then we'll do the questions. Turn over to DMH.

Hi. Good afternoon. Mary Watanabe, director of the Department of Managed Health Care. The department's mission is to ensure health plan members have access to equitable, high quality, timely, and affordable health care within a stable health care delivery system. We license and regulate a 140 health plans that provide health care coverage to approximately 30.2 calif million Californians.

This includes about 13,000,000 Californians with commercial health care coverage. I'll move on to your first question, which is an overview of how gender forming care is offered by commercial health plans. So commercial health plans licensed by the DMHC are required by California law to provide health plan members with medically necessary gender forming care. If a health plan is not able to provide medically necessary gender forming care within their network of providers, they must arrange for the care outside of their network.

If a health plan denies a service or treatment, they must provide a reason for the denial to the member and how to file a grievance with the health plan to appeal the denial.

Health plans are required to use the clinical criteria developed by nonprofit associations for the relevant clinical specialty when making medical necessity determinations. For services to treat gender dysphoria, health plans are required to use the word World Professional Association for Transgender Health or WPATH guidelines. You heard earlier, Calvary law prohibits plans from denying health care or discriminated against individuals because of their gender, including gender identity or gender expression.

There is no age requirement associated with providing services if it's determined to be medically necessary by the treating provider and the health plan. In terms of your question about how health plans ensure access for care for their members, health plans are required to have an adequate network of providers to ensure access to behavioral health services, including services to treat gender dysphoria.

The DMHC annually evaluates health plan networks for compliance with geographic and provider to enrolls enrollio ratio requirements. Health plans are also required to submit annual reports dealing detailing compliance with timely access standards. The DMHC's network adequacy review is focused on the availability and accessibility of the provider types necessary to deliver covered services, which includes certain access standards that apply to the types of providers that deliver gender affirming services. This includes psychiatry, endocrinology, plastic surgery, counseling mental health professionals, and family planning to name a few.

While there are no specific gender affirming care providers, these providers may elect elect to obtain gender affirming care related certifications through WPATH or take advanced continuing medical education courses.

And the third question was, does DMHC track the adequacy of provider networks for the delivery of gender affirming care, and what measures exist for how easy or difficult it is for Californians to access gender affirming care. The DMHC does not specifically analyze the accessibility and availability of gender affirming services because there is no specific network adequacy standards associated with these services. As discussed in the previous response, we evaluate the plan provider networks to ensure members have access to providers that may provide gender affirming care services.

We ensure health plan members receive access to gender affirming care by monitoring complaints and independent medical reviews or IMRs received by our help center. The help center's complaint process addresses issues related to to denial of coverage for services based on the plan's assertion the services are not a covered benefit or if the health plan member cannot access medically necessary care within timely access standards.

The independent medical review process is available if the health plan denies, modifies, or delays services because the plan determined the requested service is not medically necessary or is experimental or an investigational. If the an IMR is decided in the enrollee's favor, the plan must authorize the treatment within five business days, and every IMR decision is posted with a summary on our website.

If a member is not satisfied with their health plan's resolution of the grievance or has been in the plan's grievance system for thirty days for non urgent issues, they could should contact the DMHC help center for assistance. We investigate and take enforcement actions against plans that violate the law. These violations are often discovered by our DMHC help center.

We have also cultivated meaningful relations with many advocacy organizations representing and working with members of the transgender, gender diverse, or intersex communities. We frequently engage with these organizations to discuss access concerns and provide information about the health center. Through these engagements, we've learned about some of the issues the TGI community experiences, including discrimination, lack of provider culture cultural competency, coverage denials, and lack of access to gender affirming care providers.

Regarding the final question about statutory changes or other changes, to strengthen protections for Californians enrolled in commercial health plan coverage. We would just continue to encourage health plan members experience experiencing challenges accessing gender affirming care to contact our help center.

We work directly with the member in the health plan to address these issues. This also helps us identify where there are barriers to care. We also have a TGI web page on our website at www.dmhc.ca.gov. The site is intended to educate Californians on their health care rights, including access to germ gender affirming care. And that concludes my presentation.

Good afternoon, chair and the committees. My name is Tyler Sadrith. I'm the state Medicaid director at the Department of Health Care Services. I'd like to just provide information about this topic in Medi Cal. Gender affirming care is a covered Medi Cal benefit when medically necessary.

Gender affirming care refers to services provided to address the incongruence between a Medi Cal Member's gender or sex assigned at birth and their gender identity. Services must be rendered by providers specially trained and experienced in providing culturally competent gender affirming care services. The department supports and ensures access to medically necessary evidence based gender affirming care for medical members in alignment with state law and its mission to promote the health and well-being of all Californians.

Recent federal actions disregard established peer reviewed evidence based research showing gender affirming care is effective, medically necessary, improves health outcomes for Medi Cal members. As another panelist shared, CMS recently issued three proposed rules and one declaration by The United States, health and human services secretary Kennedy.

One proposed rule with amendments to, federal hospital conditions of participations would ban hospitals participating in Medicare and Medicaid from providing puberty blockers, hormones, or surgery for treatment of gender dysphoria in minors. The second proposed rule would prohibit Medicaid and CHIP funding for puberty blockers, hormones, surgeries to treat gender dysphoria in persons 18 in Medicaid or 19 in CHIP, although mental health services would continue to be covered.

The third proposed rule would classify gender dysphoria not resulting from physical impairment as excluded from the federal definition of disability. So those are proposed rules. The secretary's declaration, which was issued not as a proposed policy, but as final policy, declares puberty blockers, hormones, and surgeries to be unsafe and ineffective as treatment for gender dysphoria in minors.

The declaration sets up the basis for excluding providers who deliver gender affirming care from all federal health care programs, putting all of their reimbursement at risk, not just reimbursement for gender affirming care. This declaration is currently being challenged by a multistate coalition, including California, with a summary judgment granted in favor of the plaintiff.

In February, the California Health and Human Services Agency in part in partnership with the department and other state departments submitted public comment letters articulating strong opposition to the proposed rules, noting it would restrict access to medically necessary gender affirming care and would harm Medi Cal members. It the agency expressed concerns with the proposed rule and the potentially devastating effects it would have on the lives of some Medi Cal members and their families.

California law protecting access to gender affirming care in Medi Cal remains fully in effect.

Services is expressly protected under state law. Proposed federal rules are not final and do not carry the force of law at this time. Accordingly, California's Medi Cal and SHIP policy continues to guarantee coverage of all medically necessary gender affirming care backed by state law and existing departmental guidance. The department is committed to ensuring timely access to gender affirming care, including pharmacy services, medical care, mental health care, surgeries, and related ancillary services.

We have a history of providing guidance to Medi Cal managed care plans to affirm and establish these requirements.

Plans and providers may not deny or limit care based on a member's gender identity. Coverage decisions must rely solely on medical necessity consistent with clinical guidelines established by multiple medical societies, including WPATH, the Endocrine Society, the American Academy of Pediatrics, and the American Psychological Association. The Medi Cal provider manual requires all gender affirming services be rendered by providers specially trained and experienced in providing culturally competent gender affirming care.

The department has issued all plan letters in the last few years to reinforce this policy, including in 2024 regarding transgender, gender diverse, and intersex cultural competency training, in 2018 regarding access to transgender services, and in 2013 2016 regarding transgender access requirements. The department and the California Health and Human Services Agency are preparing strategies to maintain access to these services if the federal proposals are enacted.

Thank you. Thank you so much. That concludes our presentation from the first panelist. I'm gonna be bringing it back to our subcommittee. I can kick us off if oh, I can kick us off. Okay. I'll kick us off. Great. Thank you. I'll start with d o DOJ.

So the attorney general sent a in response to children's hospital saying they were gonna close their program. The attorney general sent out a a letter reminding providers of their obligation under state law, But said providers continue doing that what they were doing, what happens next after the letter was sent?

So I believe you're referring to Children's Hospital Los Angeles. So we are continuing to closely monitor the provision of care across the state. And as as I said, we are taking action against Rady Children's Hospital, for deciding to try to end their entire program. So we are working diligently to make sure that hospitals are following their obligations.

But Sutter, Kaiser, and Children's Hospital have all stopped programming. I'm wondering why we haven't taken action in the on those hospitals.

I'll defer to my colleague for that. Yeah.

Again, we are continuing to monitor the situation. We're not at liberty to discuss any strategy that may be up for consideration and certainly not on something as delicate as this matter.

But Rady's Hospital came a little after the other hospitals. So why that hospital?

Sure. So Rady's Children's Hospital is under attorney general conditions. There Is it the The attorney yes. The attorney can you or you can hear me?

The attorney general approved the merger of Children's Hospital of Orange County and Rady's Children's Hospital San Diego in 2024 and imposed conditions that required Rady, the surviving entity, to continue to provide the same level of care that existed when the merger was approved. And that's for a period of ten years and specifically called out was gender affirming care as well as other services. So in that situation, we it it was necessary to ensure that this vital hospital continued to provide that care.

When the AG approved those conditions, it took into consideration that what was left was a hospital that basically controlled children's health care in that area of the state, San Diego, Orange County. And if a hospital that provides that much care in that region stops providing gender affirming care, then that really leaves the patients with very few choices.

So the attorney general found it necessary to take affirmative action to ensure that those services could continue for patients in that area.

It's a little confusing for the public when that hospital but you have the other three hospital systems that I've mentioned that are all across California. And the number one leading in the in the in the nation, Children's Hospital LA, it's a little difficult for me to say we're monitor to hear we're monitoring the situation, and I don't know what more needs to be monitored. If they outright said we're not doing this treatment anymore, I'm not sure what is wait what we're waiting for.

I recognize that you cannot share legal actions or so forth, but we're going on over a year of not having providers providing care. So So when I hear DMHC and DHCS say we're tracking and auditing, I don't know what we're tracking and auditing if there's no providers providing care.

Sure. Sure. And and I appreciate that. All along, we have found that what is really the existential threat is the Trump administration trying to intimidate these hospitals, these providers, these scientific organizations to stop supporting gender affirming care. So in this way, we we've targeted the, for lack of a better word, the source of the problem, which is the federal administration.

That does not mean that we may not proceed against additional hospitals, but right now our efforts are really to address the source of the concern that which is trying to remove the ability of any of our hospitals to provide this care at the threat of losing all of their federal funding.

Thank you. Director, to that point that I just made, you know, you mentioned that you you review equitable access. I don't anticipate Dignity or Providence stepping up to do this. So I just mentioned all the hospitals that are supposed to be providing. In your reviews, how are you determining that there still is equitable access to gender affirming care?

Yeah. No. I I mean, I think the the bottom line is our authority is over the health plans. We don't have the authority to require providers to provide gender affirming care services. I think that's ultimately the question you're trying to get at.

It's why we continue to advocate for individual enrollees coming to our health centers. So far, we've been successful in working with health plans to arrange for care, whether that's in network or out of network. So, you know, at this point, we've been successful, but we need people to come to us. As I think you'll probably hear, the number of providers and facilities willing to provide these services are dwindling, but so far, we've been successful in the cases that have come to our

And plans are still meeting that distance requirement?

Yeah. So so the the time and distance standards, the timely access standards, we have geographic and ratio standards. The plans are meeting that for those provider types broadly. So let's just take psychiatrist or surgery. They're providing services be beyond gender affirming care.

We don't have specific requirements specific for gender affirming care services because there's not a specific specialty type for gender affirming care specifically.

Okay. And then one of before I turn it over to you. Deputy director Ryan, that's your title. Right? No. What is your title? Ryan. Sorry. Ryan. Tyler. Sorry. Chief deputy director. Sorry. Sorry, Tyler. Sorry.

Ryan is my first name. Tyler is my middle name and I go by Tyler. So you were correct.

The Senator was not wrong. Okay. There was one question, and I don't know if I missed this from you. Are there any statutory changes or other actions the legislature should consider to strengthen protections for Californians?

Thank you, Senator. So I think at at this time, we're sort of keeping a close watch on how CMS will land on finalizing the proposed rules that they put out. And I think depending on what those proposed rules mean in terms of being issued and promulgated as final rules, that will help the state better understand what changes, if any, are needed. Okay. Assemblymember.

Thank you, madam chair. And first and foremost, thank you to the entire panels today. Specifically, a shout out to miss Palma and miss Adams from the, you know, the AG branch's office for all the information. In a time where, you know, our our trans community feels attacked at every level, at a time where, you know, this legislature will do everything to protect them. We are very thankful of your work because at this point, what is what what can we rely on?

It's the law. What can we rely is protecting our community through a legal lens. Yes. I mean, I have questions of what else can we do as legislature. It'd be in the lens of, you know, budgetary, secretary, or or, you know, legal for that matter.

Right? So I think I I remain committed on behalf of so many caucuses in in the at least the respectfully on the Democratic side of of our of our legislature to protect the communities. And I invite anyone from the other Ohio to come and protect. This is about a humanity issue and ensuring that community, our youth, our our seniors population, they feel protected.

And so for me, I I just applaud the work that the DOJ is doing because that's that's the one area that I feel confident that we're gonna fight back the attacks on these on on the community.

So with that, I know that the assembly remains committed. I appreciate both miss Addis and miss Menjivar as they lead this discussion, and I appreciate any information that we receive, from our offices and how we also we do. So if any feedback that you might provide on what else can we do, besides what you already doing from a from a, you know, a staff perspective, what else kinda looks like you do to help advance these protections?

I can say from the Department of Justice's perspective, we are fully committed to working with the agencies on any potential legislative strategies. So, we definitely defer to their expertise and look forward to coordinating with them.

And and just just on that note, some of your colleagues have introduced bills to strengthen our shield laws.

Right.

Those are very important. Obviously, we're here to protect the patients. We're also here to protect our providers who are providing the care to this community. So I think that that that would go a long way as well to sort of bridge bridge the gap on any sort of holes that exist in our shield laws.

Thank you.

We're we're past the sixty days of the public comment for the federal proposed federal rules. When do we anticipate do we anticipate anytime soon? We don't know. Okay.

We're just waiting to see. Yeah. You know, there there are various rumors that might float around, but at the end of the day, we we don't have any insight into exactly when they'll

Have they appealed the vacate I don't know legal terms, vacate of the Kennedy declaration?

So because there is no written ruling yet, there is no ability to appeal. So the the court did make an initial ruling from the bench, but that was not the full final written order.

Alright.

So that's what we're waiting for. Once the district court makes that ruling, then things can proceed from there.

Okay. What are the chances that any of these get to the Supreme Court?

I mean, I don't know. I'm I'm not a 100% sure, but I do think that this is a very controversial issue, you know, as as we've seen. So I think it's certainly possible, and we are ready to fight to protect this care any way we can.

Thank you, chair. I wanted to address the the basic fact that gender affirming care in the state of California is actually an obligation and a protected service for providers, health plans, and others. That's that's kind of our basic that's our basic standard. I wanted to just touch a little bit on director Watanabe's point about the adequacy of provider networks.

I think I heard you say that the delivery for the providers for delivery of gender affirming care is not something that is categorized in order for you to be able to adequately track. Is that correct?

Yeah. No. And let me just say for like, let's just say psychiatry, there is not like a special designation for psychiatrists that provide gender affirming care or other specialties. So we're looking broadly at the category of a provider type, and we have standards there, but looking at at like specifically for those that provide gender affirming care is not something that there's like a special license or something that we look at specifically.

So in terms of something that the legislature could look to do in terms of establishing a framework that could further clarify our determination and commitment to provide gender affirming care and services. One of the things that we could possibly do is look to make sure that we're very clear about that designation across different different providers. Right?

Yeah. I mean, I think we'd have to look at the license. So there needs to be, like, a licensing structure around a specific type of provider that would provide gender affirming care. I'll just say, I mean, I think we'd wanna think very carefully about that. There is already a tremendous amount of fear from providers who are provider providing gender affirming care to indicate that they are a provider that is providing those services in provider directories.

So again, wanna be thoughtful about anything that we we don't wanna make it worse than it is now, but I think we'd have to look at is is there a special certification or licensing process for a provider specific to gender affirming care?

The challenge though without having that specific licensure is that we don't have any ability right now to track and therefore understand whether or not we are actually providing that care to Patients who are in need of in need of that medically indicated care.

And we just to be clear, we don't collect utilization data, for example, either. So we're we don't track, like, the number of individuals that are accessing these services either. But but, yes, I I just there's this challenge of there's not the specific specialty for gender affirming care, so we're looking broadly at the types of providers that provide these services.

That means that we have a significant gap, and I understand the sensitivity, but I also just wanna acknowledge and recognize that it creates another another challenge for us where we are actually not able to determine whether or not we are providing that we are meeting the network at adequacy commitments that we are obligated to do so. So one area of investigation for sure. I think connected to that is one of the I could be sitting in a coffee shop walking down the street in the supermarket.

One of the things that always happens to me in those spaces is that a very, very desperate parent will come up to me and say, please make sure that my child has continuity of care as they're going through their transition process. Without a doubt, it is it is the most desperate plea that I ever have to deal with in my district.

What in your estimation I heard you also speak to the kind of on the back end things that you DMHC and DHCS are able to do. I'm assuming kind of similar structures. You can file a complaint. You can go through the independent independent medical review process. You can go through a denial of services process or along that.

All within a period of time. So we know that not having continuity of care is incredibly critical and and in the meantime, people's lives are kind of deteriorating significantly while they're not receiving those. So so those are things on the back end that we are able to do through our agencies. Are there any things on the front end that our agency should be considering to be able to provide proactive and prospective directives to providers and facilities to ensure that there isn't an interruption of care.

Maybe I'll just start just to reiterate it. We don't have a authority over the provider. So our authority would be over the health plan.

Or over the health plan. Sure.

No. So just wanna be clear from DMHC's perspective, I would say not. But, Tyler, I don't know if you have any more.

So we do have certain continuity of care policy is as Medi Cal members transition from one delivery system to another or sometimes from one plan to another.

So if someone comes from the fee for service delivery system and they have a trusted relationship with the provider and then they're sort of assigned to a Medi Cal managed care plan, we have continuity of care policy is where up, you know, for up to about a year, that plan has to at least offer an opportunity for that provider to provide services to that member. The provider is not obligated to do it, but we we obligate the plan to sort of offer payment to that provider.

So we have continuity of care policies in effect today as members covered by Medi Cal transition between delivery systems within the program. Sometimes as members churn in and out of Medi Cal, obviously, we can't cover services for people who've not enrolled in the program.

So members may inevitably face some continuity of care issues if they move to another source of health care coverage or or lose Medi Cal as a source of coverage.

So getting kind of with with those responses, getting to our Senator Menjivar initial question around the the fact that we have health care facilities that are essentially made a decision to not provide care. We understand the the fundamental challenge that the Federal Government has created. They're essentially holding ransom our Medicaid and medical funding to be able to ensure that they have the ability to do that. It's a very high stakes and very egregious action by the Federal Government in my in my opinion.

What might we be able to do to help to stabilize that dynamic of providers and facilities making their own independent decisions that we then on the back end have to consider taking action around to be able to ensure that we are or health plans for the providers or institutions.

So that we don't have as much instability dictated by essentially private private institutions and providers to be able to do that. Because it's it's a it's a gray area. I recognize that, but we're clear on what California's law is. And we're clear that we intend to defend that law at at all costs. So what might we be able to do that's much more proactive as opposed to just allowing institutions to make their own independent decisions in terms of guidance.

Assemblymember, I'll offer just a thought on that. So if the if the three rules on the declaration move forward as proposed, it would, in effect, prohibit any provider that offers these services, to the impacted population, which are are minors here, from being able to receive any federal Medicaid or Medicare funding. And so there's a choice. Do you enforce a California law that, you know, says they must provide that services?

If we lean on enforcement, we would, in effect, be forcing them to forsake Medicare and Medicaid dollars.

I mean, that that is what's at stake if these rules are finalized. So one solution and would would be setting up a state only program or some state only programming or grant to allow these services to continue to be reimbursed in lieu of the Medicare and or the Medicaid revenue that is being used today. I think what's especially challenging as proposed by the rules is that it would be hard for a provider to say, okay.

I'll treat all other medical care and bill it to Medi Cal as applicable, but for gender affirming care, it's state funded. Because as proposed, the rules would bar them from participating in Medi Cal completely.

So in effect, it would be creating a state only program for a provider that operates exclusively in that state only program and doesn't participate in Medi Cal at all. So that's one potential pathway that this takes if those rules in the declaration are finalized. Thank you

Do you all have any thoughts on that in the DOJ?

None other than to say, as as my colleague mentioned, we we have every intention of challenging any such rule that would attempt to strip federal health care fundings from providers for providing this medically necessary care.

Thank you.

Assembly member.

Great. Thank you so much. Appreciate the time by everybody. Believe it or not, to my colleague on my right, I too care about people and wanna protect them. You know, and and when it comes to this topic, it is one that I am very concerned about for different reasons.

Should come as no surprise to anybody up here. But also the the realization that a lot of Western society has abandoned trans gender affirming care for children. California continues to go full steam ahead on it. And I don't you know, there have been studies after studies and we could cite them and I'm sure every single study that I give would be somehow discredited, by some facts or, you know, I mean, we could have this debate forever.

But there is a lot of scientific evidence that gender affirming care for children, particularly surgeries, is problematic, and that is why a lot of countries are abandoning it.

And in fact, the American Medical Association, which isn't exactly, you know, some liberal or some conservative think tank, does not have the same view as other institutions cited here. And so I think, you know, with that in mind, my biggest concern is our children and decisions that could be made to impact their entire life. And with that, I have a series of questions and some of them, have have, I think been answered, but I just wanna make sure I have it clear.

And I I'll I'll ask the Department of Justice since these are legal questions. And just so I'm totally clear, California health plans are required to cover gender affirming care. Correct?

Yes. So they're they're requiring that providers cannot discriminate on the basis of gender identity. And, you know, I've I've listed a number of different characteristics. So if an individual is transgender, a person diagnosed with gender dysphoria, non binary, gender nonconforming, or intersex, there's no discrimination allowed on that basis.

Okay. So you may take issue with an individual who's transitioning to receive hormone replacement therapy. Have you ever intervened in litigation in which a person who wishes to remain their gender would like to replace get hormone replacement therapy?

I'm not aware of any case that the attorney general's involved in.

It's interesting. But gender affirming care or or non discriminatory includes children, adolescents. Correct?

It does.

Okay. And, you know, recently, I have a 12 year old, and he's undergoing a, you know, medical issues, you know, none of anybody's business. But I was surprised to log in to his account, as I always do. I mean, you know, this is a he's a great young man. Also, I have to remind him every day to brush his teeth.

Yet, after his doctor's appointment, I couldn't see the clinician notes on why on what's going on. I mean, this is an individual who actually depends on me to guide him through this medical issue. Why is that?

I'm I'm not able to speak to that particular situation. I'll I'll defer to my colleague.

So so there are medical privacy laws that kick in at a certain age. And that's that's probably what you are seeing there.

It's 12 years old. Yeah. And that's a

I understand.

California specific law. There are obviously federal HIPAA laws, which California goes a step further and makes it 12 years old. What if an in what if an individual who's 12 years old is seeking gender affirming care? What kind of privacy do they have?

So there are privacy laws that cover any patient that is seeking that care. Again, I think my colleague is more well versed in terms of appearance rights in certain circumstances, but there are privacy laws that protect medical records. And we're dealing with that in the Trump administration subpoenaing of those records.

Yeah. I mean, I don't think any government agency has a right to know anybody's medical records, frankly, but which is why I've actually introduced and passed legislation in this building to get certain substances off that are none of the government's business off our controlled substance list if prescribed. But, could you help me understand, whether a child can seek gender affirming care without parental consent?

So, I think it's helpful to consider what gender affirming care is. It's mental health services. It's puberty blockers. I think a lot of, many times when this comes up as a controversial issue, it's sort of viewed as just surgery. That's not all what is is encompassed in gender affirming care.

And and you you could probably speak a little bit more to that. But when it comes to surgeries, for instance, that only happens through extensive provision of health care, oftentimes years. And there is such a small percentage of, surgeries that involve minors. The vast majority of those entail adults. So, yeah, if if if if a child is is questioning, should they be able to provide get get, mental health services or or therapy for that?

I say yes. Why not?

Yeah. I mean, that's the law of the land. I disagree with that, but that's the law of the land. I mean, I believe, my child, is much better, equipped with parental support around those, issues. And, you know, and a child, a 12 year old might think they don't have parental support when they really do.

But just to be clear, I'm not only talking about surgeries. I mean, mental health treatment, puberty blockers, you know, without the consent of parents, I totally object to. Again, consent of parents, I totally object to. Again, I know that's not the law of the land, but it does really, like, concern me though that that and I've I've been saying this a lot this year, but I am I am I when I say grown man, I mean, that's subjective. I'm pretty short guy.

But but I'm a grown man, and there are treatments that I can't receive right now because of plans or guidelines. And I don't see any support from the state of California or the Department of Justice on any of those items and laser focused on suing hospitals that that aren't giving puberty blockers to children, but not adults. You won't wanna give adults hormone replacement therapy. Won't defend that as a person's withering away, but no problem. A kid, we will defend that.

Child we will sue the hell out of that children's hospital.

Yeah. I I I don't think that the Department of Justice will come out, ever saying that it is acceptable to deny medically necessary care for children or for adults. Thinking of the medical privacy laws, it sounds like you have a very nurturing supportive family. Not every child comes, unfortunately, to the world with that type of support. Those medical privacy laws involve situations where there might be reproductive health care that's necessary because, there might be incest situations.

So it it is it is a broad law that is meant to address medical privacy under a a very vast set of circumstances. But I I can appreciate that that you you being in a loving family would would want to know. But as you yourself indicate, this this is the state of the law.

Yeah. Correct. I I understand it's the law, and you're enforcing it. And this building often makes those laws, and I object to all of them. But but just to be clear on that, I think the the issue that I have is that these laws are created for those families that don't have those supportive environments that, you know, one you know, where where we look at with a blanket.

You even said you said they were broad. That is actually my fundamental issue, is that all the loving and nurturing parents in the state of California have lost the right to their children in order to protect, as you said, the very small number of children. And that is a big problem. How am I supposed to help guide my children, four of them, through all of this if I I can't access this, you know? And believe it or not, kids lie to their parents.

Good kids lie to their parents. I lied to my parents. I still lie to my parents, you know? Hey, Joe. How's it going? It's going great, you know? So it's gonna happen, you know? I love my parents to death. Hopefully, my kids love me. Last yesterday, my son was mad at me.

But so, you know, California continues to pass laws to move this ball forward in terms of privacy for children. One of them recently was AB 1955, when my understanding is the state of California was sued and lost on six to three co decision by the Supreme Court. Where what's the status of that? Because in the schools where the where people where the peers and teachers know, is sort of where this is starting.

And so it's really important to me to understand, what the state of California is gonna do after losing that litigation on AB 1955. Because there are school districts in my district that that bills continue to be

Assemblymember I just wanna refocus. This is the health committee. I know you're talking about a bill in education. I just wanna refocus that health.

Because when these secrets are happening at schools and the teachers know, their peers know, and then later on, they're going to talk to their mental health, we've actually invested in community based mental health treatment in schools. The state has. It's important for me to know what's happening in my kids' life, and this is totally relevant. Are we gonna or is what's happening now in regards to that?

I'm gonna I'm gonna bring us back because once again, you probably got the agenda in the briefing on health, gender affirming care in health providers, hospitals, clinics. Well, these panels were not brought here to talk about what's going on in schools. I just wanna call

it back. I'll rephrase. If my child goes and sees a therapist at School, AB 1955 require that they don't inform the parents. Recently, the Supreme Court ruled six to three that that pair therapist could not talk to the children as well as the teach or the parents as well as everybody. Does the state of California continue to, implement those health care protections at the schools and keep those secrets from parents?

So, unfortunately, I don't have, an update on the status of that challenge. So, unfortunately, I cannot speak to that.

Alright. Okay. Last question, and and thank you, madam chair, for bearing with me. But a statement was made that, by the Department of Justice, respectfully, that the Trump administration is intimidating hospitals. To me, it seems like the state of California and the Department of Justice is intimidating hospitals.

After all, it is it is the state of California that's suing the hospital. So now the hospitals and and these health plans are in a situation which are trying to decipher the difference between federal and state laws, which seem to conflict. So why has the state of California opted to, and apparently looking at other situations, why is it opted to litigate against, those providing treatment in California rather than finding another avenue to litigate?

Well, so as we've testified, we are suing the Trump administration directly. That is our primary focus because as my colleague said, that's the source of the intimidation. And I will say that intimidation word is verbatim from providers and hospitals. They've been telling us that they have been intimidated into changing their policies, into feeling like they cannot provide this care anymore. They're providing declarations in lawsuits saying that they are too scared, that they need protection.

They're asking us to bring this litigation against the Trump administration. So this is a nationwide concern for providers and hospitals telling us the Trump administration is intimidating us. It's a threat. And as, Assemblyman Bonta said, it's it's really a hostage situation where they they cannot, choose whether to provide the care or to lose the funding and have to close their doors.

So this really is very much an intimidation situation, and we are doing everything we can to enforce our laws and hold Rady Children's Hospital accountable for its decision to, kind of take action before federal law has changed.

There is no conflict between federal law and state law right now. And in addition, we are trying to stay focused on the federal attacks.

Okay. I think it's a fair point if you say there has been no change in federal law. It appears the guidance will be coming soon. I hope that the state of California does not intimidate our providers, our hospitals, our health plans if they're trying to figure out, you know, between the federal law and the state law. And that's a issue we have.

I mean, take the battle up with the Trump administration if you choose. You'll win some, you'll lose some. But I I think going after our California, providers is a mistake and should really be revisited. Thank you.

Thank you. Director, I just have some couple follow-up just to clarify because the health chair brought something up that I think it just went over my head. Just to clarify, since we don't characterize or certify, we can't track if there's equitable access to gender affirming care.

So so we look at provider types. We don't collect data on individual enrollees that are under the plans that we regulate. So I don't know services accessed by one population versus another. So because you mentioned

so far that you've been able to that everyone's been able to meet.

Those that have contacted our help center so far, Marie, the end and again, I wanna be very clear. K. It is a fairly low number. Right? Right.

We want more people to call us. We do a lot of outreach to try to get more to call us because so far, we for those that have contacted us individually, where we've been able to work with the plans to find a provider that can provide services.

And that's the help line you mentioned? Our help center. Yes. And then the TGI website also shares information? Correct.

Yes. There's a lot of information that links to both DHCS, Department of Justice, health care rights, a lot of good resources. So dmhc.ca.gov.

Okay. Department of Finance, I don't know if you can help me. I asked this question last time. We allocated 15,000,000 to help with gender affirming care. Has that been utilized yet?

Running out of chairs. Joseph Donaldson, Department of Finance. So as noted, we did include that 15,000,000. I believe Covered California is still implementing those dollars. I believe they'll be providing program updates and some of our forthcoming committee hearings.

So I would defer to Covered California on kind of the implementation of those dollars.

Okay. I don't know if you have any questions on that. We can move on to the next panel. Okay. Thank you so much for participating in our first panel. Our second panel is gonna focus on how providers and families navigate access to gender affirming care.

Whoever's the doctor we'll start with you, doctor.

I'm the doctor. I just play one on TV. No. Just kidding. Thanks for having me today.

My name is doctor Johanna Olsen Kennedy. I wanna talk a little bit about the history of gender affirming care, but also the present state of gender care in The United States. The medical care for transgender patients began nearly a hundred years ago. Magnus Hirschfeld began documenting and treating trans patients in the late nineteen twenties at his institute in Berlin until it was burned down by the Nazis in 1945. The first recorded genital surgery occurred in Germany in 1931.

This surgery happened shortly after the synthesis of estrogen in 1930. Testosterone was synthesized in 1935, and doctor Michael Dillon became one of the first trans men to access masculinizing hormone therapy in the late nineteen thirties and forties. Doctor Harry Benjamin began treating transgender people in The United States in the nineteen sixties and seventies and was the catalyst for the development of the World Professional Association of Transgender Health Standards of Care.

Doctor Benjamin received hundreds of letters from people interested in obtaining medical care, including youth as young as 14. In the nineteen seventies, care became increasingly accessible through academic institutions across The United States.

And as it did, opposition to the care was also on the rise. Utilizing the same tactics as we are seeing today, predominantly citing lack of evidence, Academic clinics began shutting down, and by 1979, they were all shuttered. Medical care for transgender patients was all but unavailable except in private practices and community clinics. Medical care for transgender patients did not move back into academic centers until the HIV epidemic.

I am the former medical director of the Center for Trans Youth Health and Development at Children's Hospital Los Angeles.

We began treating transgender adolescents and young adults in 1991, and the clinic was likely the earliest of its kind in The United States. I trained as a fellow in adolescent medicine. I am board certified in both pediatrics and adolescent medicine at Children's Hospital LA from 2000 to 2003, and shortly thereafter began providing medical care for transgender youth and young adults.

In 2006, the use of generates analogs, what we call puberty blockers in the lay community, was introduced into the world of medicine by a team of providers in The Netherlands. It was so clear that experiencing the irreversible aspects of puberty is one of the most distressing experiences for transgender individuals to undergo, particularly transgender women who cannot go back and ungrow their Adam's apple, their vocal cords, their tall stature, their facial hair, etcetera.

The introduction of puberty blockers to this area of medicine has perhaps been the single most important development since the synthesis of hormones. These kinds of medications have been used in The United States since 1980 in the pediatric population for central precocious puberty and in the adult population for a variety of medical conditions. Urinary age analogs have a long and enviable safety profile. Estrogen and testosterone have been used for decades, close to a century, in the treatment of transgender adults and adolescents.

I wanna move on to the treatment of gender dysphoria, the persistent distress caused for some people who are trans because of their gender incongruence.

Relief from gender dysphoria is the primary reason transgender people seek gender related medical care. I discussed in the history about the use of medications most commonly utilized, GnRH analogs, estrogen, and testosterone. It is really important to note that all human beings have all of these hormones in their body naturally. The goal of medical treatment is to change the ratio of these hormones in order to induce the development of secondary sex characteristics that are truly aligned with one's gender identity.

In other words, testosterone for the development of a more masculine voice, facial hair, and body shape, and estrogen for the development of breasts, softer skin, and a rounder figure that typically accompany female puberty.

Prior to accessing medical care, many, if not most, youth and families have a long process before ever seeking medical attention. The process almost always begins with the young person discovering and investigating the feelings they are having related to the discomfort around their assumed gender. In other words, maybe a feeling such as why am I uncomfortable being called she or daughter? Or why did I feel so happy when I was referred to as he?

What generally follows these feelings is a very long and private exploration of trying to understand what, how, and why these feelings are occurring, and if there are other people experiencing similar thoughts, and what can be done if anything about this discordance.

As adolescents learn more about what it means to be a transgender person, they also learn that if they want access to professionals, they must disclose this information to a parent or guardian. This process of disclosure is excruciating for many. It is my observation that adolescents often feel scared, guilty, or ashamed of learning about their gender, and they don't wanna upset their parents or create chaos in their family. Sometimes holding this truth about self leads to social isolation, anxiety, depression, self harm, and thoughts about suicide.

Prior to disclosure, many adolescents are already engaged in therapy to address those issues that are not known to other people to be related to gender dysphoria.

Adolescents, in order to receive care, must come out to their parents, And then the cycle of discovery begins anew for those parents. They too begin to try to understand what, why, and when their child started on this journey, what it means, and probably most preoccupying whether it's true, and how to proceed cautiously. Around the time of the assault on transgender youth that began in earnest in 2017, there are more than 70 programs across the country providing multidisciplinary care.

Multidisciplinary care teams include medical providers, psychiatrists, psychologists, social workers, peer navigators, case managers, and more. Multidisciplinary care has been the recommended model for both adolescents and adults since the inception of the WPATH Standards of Care in the late nineteen sixties.

I can't attest to what every single program does, but I know that many, if not most, of the centers providing this care practice in this way. Every patient is different. Every patient has different medical needs. They have different lengths of time. They're coming in at different places in their process.

It is very individualized care. Every parent or guardian has different needs as well. Good practitioners in medical care for anyone, but in this case, transgender patients spend a lot of time listening. We learn about with the process of understanding one's gender and coming out, what that's been like for the young person and their parents or guardians. We assess what changes a patient has made to feel more comfortable.

We ask about mental and medical health, both the parent and the family members as well as the patients. If patients have a therapist outside of the clinic, we ask to communicate with them. If additional therapy is warranted, we refer patients accordingly. Recommendations about medical interventions are made together with the patient, their care team, and their parents. No medical interventions can legally occur for minors without the consent of a parent or legal guardian.

None. Not blockers, not hormones, and certainly not surgery. As of this year, 27 states across the country have banned access to care for transgender minors. Many of those bans are in litigation. Many families have traveled to California to get the health care their adolescents need.

The Center for Trans Youth Health and Development at Children's Hospital Los Angeles was a beacon program. The longest established and largest program serving transgender youth probably in the world. We were leaders in the provision of care with decades of experience between all of our providers. We were innovators in research, contributing dozens of manuscripts about the impact of medical care for transgender youth. Our patients, families, and providers felt safe there.

Our care was thoughtful, compassionate, and informed by science. At the time of the shuttering, we had just under 3,000 youth receiving services. When we learned the program was being terminated, the shock and disbelief was unimaginable imaginable. As the medical director, I had not been involved in the decision making, nor were any of our clinicians. Patients were informed four days after our our team was informed through a text message followed by a certified letter.

The ripple effect was profound. Within three weeks, our team was scrambling to see as many patients as possible with the visits massively prolonged to hold the devastation being felt by patients and parents. A place where transgender young people and their families felt safe, seen, and well cared for was abandoning them because of the threat of losing federal funding for the rest of the hospital. The moral injury experienced by our patients, families, and team members will likely not be repaired for years.

Since our program was closed, our patients and families have had to seek other programs for their medical care.

Programs are scarce, and those that accept medical even more so. As happened in the nineteen seventies, transgender care is being forced to adapt to the closure of programs because of mis and disinformation. In the absence of any major administrative shift, the care will have to move into community organizations and private practices. Unwilling to abandon my patients, I left CHLA to form an independent practice. Creating infrastructure for a new health care corporation is incredibly difficult, time consuming, and expensive.

If you want ideas about how to help people doing this, make it easier for us to get contracted with insurance companies because my same patients that I was contracted with at CHLA, I'm not able to get contracted with in my new practice. New practices need to get contracts in place with insurance plans unless they intend to charge cash. But transgender patients deserve to have their health care costs covered by insurance, whether that be private or public plans.

The shift we I made had to be fast because health care is ongoing. Patients can't stop needing care to wait for offices to be established.

I was fortunate enough to have people that believed in me and were willing to provide foundational support. I wanna be clear. The cost of running a comprehensive medical practice that is multidisciplinary and includes behavioral health does not pay for itself as reimbursement rates for both medical and mental health care is inadequate. Nonetheless, transgender young people need health care, and I am here to provide such care. I know there are others who are hoping to establish practices for their patients to receive this care as well.

But the task is daunting, and it's scary, and people don't wanna do it because they're afraid for their safety. I am now seeing families that moved from states where youth care was banned. They moved down to San Diego, and now they can't get Carrot Radies. And now they're coming up to me. They're driving miles to many miles to see to see me because the program's closing.

Even before clinics were closing, getting appropriate health care for transgender youth was very difficult. But traveling to a different state or city is incredibly painful and costly, and many, many, many people cannot do it. A constant state of fear and anxiety. Every single time I see a family, I've been asked if my new clinic is gonna close if the conditions of participation are dropped in the way that we've heard earlier today.

If we apply this level of chaos and cruelty to any other medical condition, the level of brutality would be stark and indefensible.

Transgender young people do not stop needing medical care because their programs are shut down. I listened to the gubernatorial candidates speak at the LA LGBT Center, and many of them floated this idea of backfilling the hospitals. Thing is that's a very expensive way to do that. It's much less expensive to talk about setting aside money to help people provide this necessary care. I really appreciate the opportunity to share my experiences and thoughts on this platform, and I am available for any questions.

Doctor, I'm gonna squeeze in a question because I have to step out real quick. Sure. Can you share what a minor can get under the whole umbrella of gender affirming care without parental consent? Therapy. Can they go in and get puberty blockers?

No. They cannot.

Can a 13 year old go and say I want top surgery No. Without telling my parents? No. Okay. So it's just talk therapy.

Correct. And that therapist prescribed antidepressants during the after that conversation.

No. A therapist can't prescribe anyway. A psychiatrist would have to. But no. Because you mentioned

The child would have to come out to the parent to be able to get approval from their parent to move forward with anything under gender affirming care.

That's correct.

K. Thank you so much.

We're gonna continue this panel. So we've got JM Jaffe, Risha Hanscomb, Will Loaf, and Jane Doe Parent, and you're welcome to start your testimony. And it's about five to six minutes per person. I'm left here to be the bad guy to put the time limits on it, but, we just we want everybody to be able to, say their part, and then I know there will be question more questions from the dias.

I believe we have clinics coming up after this, and then we'll move on to, public comment from, from the general public.

So we have a lot to, do, but this panel is just to recap how providers and families navigate access to gender affirming care. So please go ahead and start when you're ready.

Hello, everyone. My name is JM Jaffe. I use they and them pronouns. I'm the executive director of Lion Martin Community Health Services in San Francisco. We're on Mission Street.

I've been there sixteen years, and I'm excited to just share a little bit more about Lion Martin and what we've been facing. Primary care clinic in San Francisco, and we primarily serve queer, transgender, non binary, and cisgender women. We were established over forty five years ago, and we are actually the first and currently the only trans led, federally qualified health center in the room. We are truly by us, for us, meaning that 100% of our medical providers are 80% of our staff are transgender. And two thirds of our patients are transgender.

We care for over 3,000 patients across California originating from over two fifty different zip codes. Federal poverty level. We do accept commercial, Medicaid, Medicare, and we see uninsured, undocumented clients, regardless of ability to pay. So earlier in my career at LY Martin, I actually started as a trans health manager and I advocated for both my own medically necessary gender affirming surgery through my employer sponsored coverage at Kaiser twenty twelve, and through the IMR process, got it approved.

And I then subsequently helped over 2,000 individuals get gender affirming surgery through their insurance, through the appeals and the IMR process from 2010 to today.

After review across multiple insurance companies, you know, advocating for each surgery that came across our desk, we helped change the landscape of access in gender of for gender affirming care in California, which then rippled across the entire country. Right? We saw New York follow suit. We saw all these other states follow suit and, kind of mimic that process. Health plan policies were then updated to reflect these evolving standards of care once we held them to account through the appeals process.

The Insurance Gender Non Discrimination Act passed in 2005. We didn't get the first medical surgery covered until '2 until 2010. We didn't get the first vaginoplasty until 2012. We didn't get the first FFS until 2015. Right?

This has been an ongoing process. And so I know that, you know, we are in a new situation where we are battling this again, but I I say this to really bring back us bring us back to the history of how we got this landscape to be how it is today. And it's through the appeals and IMR process in holding these insurance companies to account.

Specifically talking about Lion Martin and the federally qualified health center space, you know, as these federal attacks have escalated on transgender health care, we're seeing real impacts on our operation, our staffing, our strategic planning. We've had to withdraw from or avoid applying to federally sourced contracts, including state contracts that are federally sourced and city contracts that are federally sourced.

Right? Lyon-Martin we are in a Unique position being a look alike health center, so we don't have that $3.30 funding for them to dangle over us. But we do have our reimbursement through PPS, and so our status itself is very important. But it does differentiates us a little bit from other FQHCs that do have that federal grant being, basically toyed with. Right?

So I do wanna make that distinction. But at the same time, because of our protected status, we are actively increasing access to minors for our care because we saw the hospital systems start shutting down. We did not see the state or the city come to our savior, and so we just, you know, because we have the expertise decided to open our doors to minors. And that has resulted in a lot of unexpected expenses as you can imagine.

And, unfortunately, you know, because we're also seeing cuts on the city level because of all the trickle down cuts that are happening, this cost shifting from the Federal Government to the state to the state to the city to the city to the CBOs to the CBOs to the CEOs to the patients is really what we're seeing happening.

Right? So our community based organizations are footing the bill. Our patients are footing the bill when this is, supposed to be covered care in California. Just as an example, you know, we just won a award through CDPH for 450 k a year for us, and then we lost 400 k from the city. So it's kind of a wash.

Right? And so we really ask that, you know, the the the state and the cities all be working together to really bolster this work. As an FQHC, we are mandated by both mission and law to serve all patients regardless regardless of ability to pay. And today, transgender health care is integrated in some form across most community health centers in California. Care for transgender youth, however, has been largely concentrated in hospital based specialty clinics.

And as these hospital based clinics are closing, the care is being shifted over to community health centers. Thousands of young people and their families have lost access access to care almost overnight, and we're going to see another 10,000 kids without gender affirming care providers looking for new providers at clinics where we only serve 3,000 people per year. Right? So we're talking about almost double needing to double our size to really even remotely provide care to this, patient population.

So as this network erodes, we really are just coming here to ask that you all really understand that this cannot our we cannot fill this gap without money.

We can we need funding in order to scale up to get new clinics. Right? Like, we have a capital campaign happening to expand our space and move to a space that's twice our size, have twice the capacity. But the funding for that is nowhere to be found. And we are applying to every state grant we can find, and we're not seeing state agencies prioritize transgender health.

So we're we're putting forward this ask for $26,000,000 to really save transgender health care in California, to save the transgender people who are rely on California for this care, and to not leave us in the in the dust. Thank you so much for listening.

Thank you to committee chairs, Assemblymember Addis, and Senator Menjivar. Thank you so much for this opportunity and all those assembled here today. I'm grateful for this opportunity to share our story. My name is Raysha Hanscomb, and I use she/her pronouns. I am so proud to be mom to Will and a sibling.

I'm a member of the Rainbow Families Action Group, and we've come together to grieve and share resources about how to support each other and our kids in response to escalating attacks on trans youth and our families.

RFA has been contacting representatives, protesting, rallying, and connecting all over the state, dreaming of and demanding an environment where our kids could just be kids and receive the care they need. Thank you. All the while living in a constant state of worry knowing that access to gender affirming care could end at any time because of these federal attacks. Our story began almost six years ago when my son, Will, was 11. He bravely came out to our family as trans.

And two years later, Will experienced debilitating decline in mental health in the form of anorexia because his gender dysphoria became unbearable.

You're doing amazing. You're doing amazing. You're doing amazing.

Oh, thank you. Thank you. I'm grateful to our providers at Kaiser who supported his recovery and delivered care tailored to my son's need needs. And now at almost 17, they continue to support Will by delivering evidence based, thoughtful, and safe gender affirming care. His story, like many trans youth nearing high school graduation, includes gender affirming surgery as an important part in preparation for college or before launching on their paths to adulthood. When Kaiser put a pause on gender affirming surgeries in July, we were crushed.

We did not hear the news from our trusted providers, but through the media. Communication at Kaiser became more sporadic, and we tried to speak to our endocrinologist about surgery referrals, but the process of surgery consultation remained unknown. We were encouraged to look out of network. My family and many families receiving gender affirming care experience anxiety, confusion, and disbelief that hospitals would defer care that's so important.

While only a few institutions like Children's Hospital Los Angeles have closed their gender affirming care programs entirely, all families are fearful that care could end at any moment.

Many institutions, including Stanford in June, Kaiser in July, and now UCSF, or just a few weeks ago, have stopped providing gender affirming surgical care or made it extremely difficult to access surgical care. Due to the immense federal political pressures and pre compliance from hospitals even in California where this care is supposedly protected, We're constantly wondering if our medications will continue to be available and whether the care of experienced and ethical physicians will be among the care levels denied to us next.

Our team at Kaiser couldn't give us concrete timeline for six months about surgery referrals. They encourage us to go out of network. And so in January, after researching, calling, and inquiring, I found a surgeon and scheduled a consult even if it meant I would have to pay out of network fees.

I learned that this particular surgeon was engaged by Kaiser already. And as a Kaiser patient patient, I had to follow the rules of their contracted relationship and we canceled our appointment. From this office, I learned that new Kaiser referrals might begin by the February. This time came and went, and we got back in line with Kaiser patients hoping that the cost of surgery would still be covered by Kaiser before the rules changed again, and that Will would indeed have the surgery before leaving home for college.

And now here we are in April, after nine months of inquiry, back and forth with a surgeon and lots of emotional turmoil, Just five days ago, we were granted an initial surgical consult scheduled with Kaiser in hopes of a referral to the surgeon I had originally contacted.

I'm hopeful, but until the day of surgery, I won't feel confident that this ride is over. I wanna be clear. Our providers are caring and information seems to be changing all the time, but families I've spoken with are experiencing this emotional roller coaster and deferral of services not just at Kaiser, but across the entire health care system and in all aspects of care is scary. This includes trans youth and adolescents on hormone blockers or trans youth receiving hormone replacement therapy and surgery.

These are scheduled procedures recommended by trusted providers that for some have been canceled or deferred with no explanation, and families must scramble to find alternative care.

As far as I understand, based on communications with a network of hundreds of families with trans and non binary kids and what we hear from hospitals and health care providers, the number of surgeons currently providing surgical care to youth 19 and who accept insurance numbers two statewide. Two surgeons to serve all of California's trans teens and families. Even if only a small number of trans youth decide to pursue surgery 18, we know that access to this care is severely limited and delayed at this point.

I'm a member of a group of loving parents with teenagers on their last years of high school trying to experience high school, and we want to be present to support our children in recovery after a gender affirming surgery and before they leave our homes. I know of families who have taken action on their worst case scenarios and have moved outside of The US or seeking gender affirming care in surgery in Mexico or Canada or further abroad.

These are financial and psychological burdens for all, and our lives are being severely impacted as this care is at extreme risk because of federal attacks. The continuity of care for trans youth, as we have heard, is imperative because gender dysphoria is a huge daily concern, and watching these hospitals and health systems fail one by one does not feel safe. Will and I are among the privileged to have insurance even in a system that feels unstable. There are so many without coverage who desperately need this care.

I ask you as lawmakers in one of the few US states where government is actively conducted by the people and working for the people, and I've witnessed that today.

There's so much happening here in support of trans youth. And will you please fulfill your obligation to protect our kids' right to health care? Please support this 26,000,000 one time general fund investment to protect and stabilize access to care for transgender kids and their families and make sure that families like ours continue to have this essential care for our kids in this highly uncertain and unstable environment. It's absolutely critical for all trans kids, for kids screaming to be their best selves.

For my son, who's here today, he's an exceptionally human. Thank you.