Read CPEHN’s analysis of the 2023-2024 State Budget. From January to July, the Governor, Legislature, advocates, and community partners debated how California’s historic surplus should be used.
The California Pan-Ethnic Health Network
For Immediate Release
January 10, 2023
Contact: Kiran Savage-Sangwan – (530) 574-2551
Governor Newsom Releases $297 Billion Budget that Advances California Toward Universal Health Care Coverage but Fails to Provide Necessary Investments in Health Equity
Sacramento, CA- The California Pan-Ethnic Health Network released the following statement upon the release of the Governor’s proposed $297 billion budget:
“Despite the expected $22.5 billion shortfall within the budget, CPEHN is grateful that Governor Newsom has proposed no cuts to eligibility or benefits within Medi-Cal, and continued the commitment to Health4All, to cover all income-eligible Californians in Medi-Cal, regardless of age or immigration status, beginning in 2024. Medi-Cal is the cornerstone of health equity in California. The Governor’s commitment to reforming and expanding the program is laudable.
“Instead of taking additional steps this year to advance California to universality, Governor Newsom is attempting to transfer more than $300 million from the individual mandate penalty which was approved for the specific purpose of making health care more affordable and ensuring greater access to care for Covered California beneficiaries (e.g. by strengthening subsidies, eliminating deductibles, reducing cost-sharing and capping out-of-pocket costs), to cover other budget priorities instead. Furthermore, CPEHN is concerned with the impact on vulnerable communities of reducing certain COVID-19 pandemic response spending, including public health outreach, at a time when COVID-19 rates are trending up again, bivalent booster rates are lagging, and new variants are emerging. Lastly, we are disappointed that there are no new investments focused on health equity, for example by investing in innovation for racial justice or enhancing data to reduce disparities.
“While there is modest investment in the Office of Planning and Research to establish the Racial Equity Commission, significant statutory fixes are needed for the Commission to achieve meaningful outcomes for California’s communities of color.
“There is still critical work to do despite the temporary budget deficit. We look forward to working with the Governor and the Legislature to advance health equity, racial justice, access, and public health in the year ahead. Expanding health equity and access will take a long-term vision and unwavering commitment. Our shared values of equity and justice will help us usher in a better future for all Californians.”
FY 2023-2024 Analysis
Governor Newsom Releases $297 Billion Budget that Advances California Toward Universal Health Care Coverage but Fails to Provide Necessary Investments in Health Equity
On Tuesday, January 10th, Governor Gavin Newsom released his $297 billion proposed budget for the 2023-2024 fiscal year. Despite a $22.5 billion projected deficit, the proposal maintains many important budget investments approved in the current FY 22-23 state budget including the state’s expansion of full-scope Medi-Cal to all low-income eligible adults regardless of immigration status, funds for Cal-AIM implementation, expansion of behavioral health, and reproductive justice services.
While the budget maintains critical spending on Medi-Cal eligibility and benefits, the Governor proposes to transfer more than $300 million from the individual mandate penalty to the General Fund to pay for other budget priorities. Previously investments were approved for the stated purpose of improving health care affordability in Covered California, including elimination of deductibles, reduced cost-sharing and a cap on out-of-pocket costs. Furthermore, despite rising COVID-19 rates, lagging bivalent booster rates, and emerging new variants, the Governor’s budget contains some spending reductions related to COVID-19 community outreach and response.
The budget fails to include new investments focused on health equity, for example, by investing in the Health Equity and Racial Justice fund or enhancing health plan data to reduce disparities. While there is a modest investment in the Office of Planning and Research to establish the Racial Equity Commission, significant statutory fixes are needed for the Commission to achieve meaningful outcomes for California’s communities of color. There is still critical work to do despite the temporary budget deficit. CPEHN will work with the Governor and the Legislature to advance health equity, racial justice, access, and public health in the year ahead. Expanding health equity and access will take a long-term vision and unwavering commitment. To view the full budget proposal click here.
Overview:
- $297 billion total budget
- $223.6 billion General Fund
- $22.5 billion projected revenue shortfall
- $35.6 billion reserves
- $22.4 billion Rainy Day Fund
Highlights of the State Budget:
- Maintains Expansion of Full-Scope Medi-Cal for All ($844.5 million in 2023-24, $2.1 billion in 2024-25, and approximately $2.5 billion ongoing). The proposed budget moves forward with the expansion of Medi-Cal to over 700,000 income-eligible adults ages 26 to 49 regardless of immigration status, effective January 1, 2024. California has successively expanded full-scope Medi-Cal eligibility to undocumented children, young adults, and seniors. Adding undocumented adults age 26-49, ensures that all Californians are eligible for health care coverage, including comprehensive dental benefits and mental health care services.
- Fails to Provide Additional Affordability Assistance for Covered California Enrollees: The Governor proposes to transfer $333.4 million from the individual mandate penalty, which was approved for the stated purpose of improving health care affordability in Covered California including through the elimination of deductibles, reduced cost-sharing and a cap on out-of-pocket costs, to pay for other budget priorities. Money for affordability assistance is defunded through 2025, despite help California families need in order to pay for the high cost of deductibles which are set to rise to nearly $5,000 in 2023.
- Reduces funding for state COVID-19 direct response: Governor Newsom’s proposed 2023-24 state budget assumes reduced COVID-19 direct response expenditures of approximately $614 million through the California Emergency Relief Fund. As opposed to a budget cut, these reduced funds likely reflect a reduction in expenditures for the current COVID-19 responses under the state’s SMARTER plan. For context, the 2022 Budget Act invested $1.8 billion one-time California Emergency Relief Fund to continue to respond to the pandemic as well as provide a roadmap for ongoing emergency preparedness.
- Fails to Include new Investments Focused on Health Equity: Once again, the Governor’s proposed budget fails to include funds for a Health Equity Racial Fund or funds for enhancing health plan data to reduce disparities. Both Covered California and the Department of Health Care Services are requiring their contracted health plans to achieve National Committee for Quality Assurance (NCQA) Health Equity Accreditation (HEA) by 2023, or 2026, respectively with California’s Public Employee Retirement System expected to align as well. Funds should be set aside to guarantee state enforcement of data equity standards.
Delays Implementation of Community Health Worker/Promotoras Workforce Grants ($133 million) to recruit, train and certify 25,000 new community health workers by 2025, in areas such as climate health, homelessness, and dementia. While the program remains fully funded, the funds would be provided later than initially anticipated including $65 million in both 2024-25 and 2025-26.
Expands the Use of Institutions for Mental Disease as part of the Behavioral Health Community-Based Continuum Demonstration ($6.1 billion ($314 million General Fund, $175 million Mental Health Services Fund, $2.1 billion Medi-Cal County Behavioral Health Fund, and $3.5 billion federal funds): California proposes to seek federal Medicaid approval to expand access and strengthen the continuum of mental health services for Medi-Cal members living with serious mental illness and serious emotional disturbance through a proposed Medicaid Section 1115 demonstration. This proposal would expand the use of Institutions for Mental Disease (IMDs), inpatient psychiatric and residential treatment facilities with more than 16 beds. An expansion of IMDs by the state would impede efforts to expand and strengthen community-based behavioral health services and would disproportionately harm the Black, Indigenous, People of Color (BIPOC), and Lesbian, Gay, Bisexual, Transgender, and Queer Plus (LGBTQ+) people of California.
Medi-Cal/Health Care Systems
The Governor’s budget includes $230.5 billion ($71.5 billion General Fund) for all health and human services programs in 2023-24.
Despite the expected budget shortfall, the Governor’s budget maintains many of the recent investments made to Medi-Cal including:
- the expansion of Medi-Cal eligibility for all Californians, including undocumented adults, aged 26-49
- funds for implementation of Cal-AIM
- efforts to expand the continuum of behavioral health treatment capacity
- the inclusion of new culturally and linguistically responsive community health worker/promotoras and doula benefits and services in Medi-Cal, and
- investments in reproductive health care and efforts to lower the cost of prescription drugs
The budget also includes several new budget augmentations including:
- a proposed five-year expansion of behavioral health services for Medi-Cal beneficiaries living with serious mental illness and serious emotional disturbance
- additional funds for the CARE Act, and
- implementation of a 988 suicide hotline
More broadly, the budget includes new and additional funds to tackle opioid and fentanyl response, improve access to reproductive care and to expand the impact and reach of Cal-AIM, particularly for justice-involved populations, homeless or at-risk and those transitioning out of institutional levels of care.
Additional Details on Medi–Cal
Medi-Cal Projected Caseload & Expenditures: The Governor’s Medi-Cal budget includes $137.7 billion ($32.3 billion General Fund) in 2022-23 and $138.9 billion ($38.7 billion in General Fund) in 2023-24 to cover an estimated 15.2 million Californians in 2022-23 and 14.4 million in 2023-24 – more than one-third of the state’s population. The Budget projects total Medi-Cal expenditures of $38.7 billion General Fund in 2023-24, an increase of $6.4 billion General Fund compared with the revised 2022-23 expenditures. A majority of the increase is attributable to the shifting of repayments to the federal government related to state-only populations from 2022-23 and the assumed loss of increased federal funding consistent with the end of the federal Public Health Emergency while costs for caseload persist through the year. These costs are partially offset by one-time expenditures budgeted in 2022-23 that are not continuing into 2023-24.
- Federal Public Health Emergency (PHE) Extension: The Governor’s proposed budget assumes a two-quarter extension of the federal Public Health Emergency through mid-April 2023 and enhanced federal funding through the end of the 2022-23 fiscal year. The May Revision will reflect the phasing out of enhanced federal funding at the end of the federal PHE.
Maintains Expansion of Full-Scope Medi-Cal Eligibility for All ($844.5 million in 2023-24, $2.1 billion in 2024-25, and approximately $2.5 billion ongoing). The Governor’s proposed budget maintains and completes the expansion of Medi-Cal to over 700,000 income-eligible adults ages 26 to 49 regardless of immigration status. California has successively expanded full-scope Medi-Cal eligibility to undocumented children, young adults, and seniors. Beginning on January 1, 2024, California will expand Medi-Cal eligibility to undocumented adults age 26-49, ensuring that All Californians are eligible for health care coverage, including mental and oral health care services
Maintains Funds for Cal-AIM ($10 billion): The Governor’s proposed budget maintains the reforms to the Medi-Cal health care delivery system through the implementation of Cal-AIM.
Provides additional funds Cal-AIM Justice Involved Waiver ($109.7 million total funds for 2023-24 and $151 million in PATH funding): The Governor’s Budget includes additional funds for 2023-24 for pre-release activities. In addition, DHCS is awarding additional PATH funding to support correctional agencies to collaborate with county social services departments to support planning and implementation of pre-release Medi-Cal enrollment processes.
Adds an additional Community Support for Temporary Rent/Housing ($$17.9 million in 2025-26 increasing to $116.6 million per year at full implementation): To improve the well-being and health outcomes of Medi-Cal members during critical transitions, DHCS will seek an amendment to the CalAIM waiver to authorize an additional Community Support for use by Medi-Cal Managed Care Plans. The new Community Support would allow the provision of up to six months of rent or temporary housing to eligible individuals experiencing homelessness or at risk of homelessness and transitioning out of institutional levels of care, a correctional facility, or the foster care system and who are at risk of incurring other Medicaid state plan services, such as inpatient hospitalizations or emergency department visits.
Invests in Opioid and Fentanyl Response ($167 million in federal funds, Opioid Settlement Funds, and state General Fund, including $42 million in 2023-24 and $103 million over four years): Includes an additional $93 million in Opioid Settlement Fund over four years beginning in 2023-24 to support youth- and fentanyl-focused investments for the Department of Health Care Services and for the Department of Public Health as follows:
- $79 million for the Naloxone Distribution Project to increase distribution to first responders, law enforcement, community-based organizations, and county agencies.
- $10 million for fentanyl program grants to increase local efforts in education, testing, recovery, and support services to implement AB 2365.
- $4 million to support innovative approaches to make fentanyl test strips and naloxone more widely available.
- Also includes $3.5 million ongoing Proposition 98 General Fund to provide all middle and high school sites at least two doses of naloxone hydrochloride or another medication to reverse an opioid overdose on campus.
Enhances California’s Reproductive Health Safety Net California ($200 million/$15 million General Fund in 2024-25 for this Demonstration): Since the Supreme Court’s June 2022 decision in Dobbs v. Jackson Women’s Health Organization, California’s providers have seen an influx of patients traveling from other states to access abortion and other reproductive health services. DHCS will develop an 1115 demonstration waiver that would advance the following goals:
- Support access to family planning and related services for Medi-Cal enrollees, as well as other individuals who may face barriers to access.
- Support the capacity and sustainability of California’s reproductive-health safety net.
- Promote system transformation for California’s reproductive-health safety net.
Allocates funds for Reauthorization of Designated State Health Program and Rate Increases ($40.4 million General Fund savings in 2022-23 and $161.6 million General Fund savings in 2023-24 through 2026-27, for total General Fund savings of $646.4 million): Anticipated federal reauthorization of Designated State Health Program funding will help to cover the costs of the Providing Access and Transforming Health and CalAIM Justice Initiative. As a condition of approval of Designated State Health Program funding, DHCS is required to demonstrate compliance with minimum reimbursement levels for specific service categories. The Budget includes $22.7 million ($8.6 million General Fund) in 2023-24 and $57.1 million ($21.7 million General Fund) ongoing for primary care and obstetric care provider increases. The Administration will continue to evaluate the need for additional targeted provider rate increases at the May Revision.
Allocates funds for a Health and Human Services Innovation Accelerator Initiative: This initiative will seed a new entity and provide an initial investment so that researchers and developers can create solutions to the greatest health challenges facing Californians, such as targeting diabetes-related morbidity and mortality, addressing disparities in maternal and infant mortality faced by women and their babies, and prevention and mitigating infectious disease. Funding for this initiative will be refined over the next few months and included in the May Revision.
Reinstates the Managed Care Organization (MCO) Tax ($1.3 billion ($317 million in reduced General Fund spending) in 2023-24) effective January 1, 2024, through December 31, 2026, to help maintain Medi-Cal program funding for the Medi-Cal expansion to all income eligible individuals and minimize the need for reductions to the program. This tax renewal maintains the structure from the prior MCO Tax as approved by the federal government with minor modifications and data updates. The MCO Tax is estimated to offset $6.5 billion in General Fund spending over the next three years. The Administration will explore opportunities over the next few months to increase the MCO Tax to provide support for the Medi-Cal program.
Medi-Cal: Behavioral Health
Behavioral Health Community-Based Continuum Demonstration (includes $6.1 billion ($314 million General Fund, $175 million Mental Health Services Fund, $2.1 billion Medi-Cal County Behavioral Health Fund, and $3.5 billion federal funds). California proposes to seek federal Medicaid approval to expand access and strengthen the continuum of mental health services for Medi-Cal members living with serious mental illness and serious emotional disturbance through a proposed Medicaid Section 1115 demonstration. This proposal would expand the use of Institutions for Mental Disease (IMDs), inpatient psychiatric and residential treatment facilities with more than 16 beds. An expansion of IMDs by the state would impede efforts to expand and strengthen community-based behavioral health services and would disproportionately harm the Black, Indigenous, People of Color (BIPOC), and Lesbian, Gay, Bisexual, Transgender, and Queer Plus (LGBTQ+) people of California.
Community Assistance, Recovery & Empowerment (CARE) Act (includes $16.5 million General Fund in 2023-24, $66.5 million General Fund in 2024-25, $108.5 million in 2025-26 and annually thereafter for county costs). The CARE Act is a new court system that will lower the legal standard to order mental health treatment against the wishes of a person with a disability. The Act requires Cohort I counties to implement the CARE program beginning October 2023 (Glenn, Orange, Riverside, San Diego, Stanislaus, and Tuolumne and the City and County of San Francisco) and Cohort II counties beginning December 2024. California proposes additional funding related to clinical assessments and time spent in court by providers to assist counties with the implementation of the Care Act. The budget also includes 23.8 million in 2023-24, $12.9 million in 2024-25, and $30.9 million ongoing to public defender and legal services organizations to provide legal counsel to CARE participants. DHCS will also request new positions to implement provisions of the Community Assistance, Recovery and Empowerment (CARE) Court, including developing guidance for counties on CARE Court responsibilities relating to the Supporter Program and Implementing additional processes and measures to support ongoing data collection, validation, and reporting. Investing in a court system to solve mental health issues, especially among people who are houseless, diverts funds away from proven solutions such as equitable, stable housing and community-based services informed by directly impacted communities.
Implementation of New Medi-Cal Mental Health Outreach Requirements – DHCS is requesting new positions and expenditure authority to meet the expanded workload created by CPEHN-sponsored bill SB 1019 (2022), which requires managed care plans (MCPs) to conduct culturally and linguistically relevant annual outreach and education to ensure Medi-Cal members are aware of the mental health benefits available to them through their MCP.
988 Update – ($24.7 million in one-time plus ongoing funds): CalHHS is proposing trailer bill language as cleanup language for AB 988 to be released. California also requests new positions and expenditure authority under AB 988 (2022) to implement and maintain the new workload resulting from the statute’s oversight activities. Funds would be used for CalHHS to convene a state 988 policy advisory group to advise on the development of a comprehensive five-year implementation plan to build out a comprehensive 988 behavioral health crisis prevention, response, and care system. Additional funds would be used by the Department of Health Care Services to oversee county behavioral health plans and to support eligible 988 call center behavioral health crisis services. Funds would also be allocated to the Department of Managed Health Care to oversee heath care service plans.
Implementation of New Lanterman-Petris Short Act Data Reporting Requirements– DHCS is proposing trailer bill language to expand implementation of SB 929 (2022), which requires the Department of Health Care Services (DHCS) to collect specific demographic information about individuals held involuntary under the Lanterman Petris Act. Specifically, DHCS proposes to expand Lanterman-Petris-Short (LPS) Act data reporting requirements primarily by:
- requiring counties to collect and report data quarterly to DHCS from their local entities implementing LPS involuntary holds rather than those entities reporting directly to DHCS, and
- authorizing DHCS to levy civil money penalties against facilities and counties for failure to submit data timely.
Public Health & Racial Justice
Racial Equity:
Invests in California Racial Equity Commission and Youth Empowerment Commission: The Governor’s proposed 2023-24 budget includes $3.8 million General Fund in 2023-24 and $3.1 million General Fund through 2028-29, which includes $1.5 million General Fund that was authorized in the 2022 Budget Act, to support the state’s first Racial Equity Commission established by Executive Order, and the California Youth Empowerment Commission. The Office of Planning and Research will oversee both Commissions, which will launch by the end of 2023. CPEHN believes that statutory changes will be necessary to ensure this commission provides meaningful outcomes to California’s communities of color.
COVID-19 Response:
Reduces funding for state COVID-19 direct response: Governor Newsom’s proposed 2023-24 state budget assumes reduced COVID-19 direct response expenditures of approximately $614 million through the California Emergency Relief Fund. These reduced funds likely reflect a reduction in expenditures for the current COVID-19 responses under the state’s SMARTER plan. For context, the 2022 Budget Act invested $1.8 billion one-time California Emergency Relief Fund to continue to respond to the pandemic as well as provide a roadmap for ongoing emergency preparedness.
Public Health Infrastructure:
Maintains infrastructure investment in state and local public health departments ($300 million ongoing): Despite the budget shortfall, Governor Newsom’s proposed 2023-24 state budget maintains an annual 300 million investment for California’s state and local public health departments. This investment was substantiated in the 2022 Budget Act to support foundational public health areas such as emergency preparedness capacity, workforce, technology systems, communication and public education for state and local public health departments. Of the $300 million, around $100 million will be allocated to the California Department of Public Health (CDPH), the other $200 million to California’s 61 Local Health Jurisdictions.
Reduces funding (by $49.8 million) for state public health workforce development: The proposed 2023-24 state budget reduces funding for previously proposed public health workforce training and development programs by $49.8 million General Fund over four years. For context, the 2022 budget act allocated a total of $75.6 million one-time General Fund over three years to strengthen and expand the state’s public health workforce given challenges presented during the COVID-19 pandemic. Impacted programs likely include previously proposed CA Public Health Pathways Training Corp, CA Microbiologist Training, Public Health Lab Aspire, and CA Epidemiology Investigation. The Budget maintains $47.7 million General Fund over four years for community-based clinical education rotations for dental students and public health incumbent workforce upskilling and training.
Reduces funding (by $25 million) for state climate change resilience programs: Governor Newsom’s proposed 2023-24 state budget eliminates a $25 million one-time General Fund for Local Health Jurisdictions to develop regional Climate and Health Resilience Plans, which was previously included in the 2022 Budget Act. This program might be restored in future years depending on the budget outlook.
Other Health Programs
Fails to Provide Additional Affordability Assistance for Covered California Enrollees ($333.4 million): The Governor proposes to transfer $333.4 million from the individual mandate penalty, which was approved for the stated purpose of improving health care affordability in Covered California including through the elimination of deductibles, reduced cost-sharing and a cap on out-of-pocket costs, to pay for other budget priorities. Money for affordability assistance is defunded thru 2025, help that California families need in order to pay for the high cost of deductibles which are set to rise to nearly $5K in 2023.
Delays Implementation of Community Health Worker/Promotoras Workforce Grants ($133 million) to recruit, train and certify 25,000 new community health workers by 2025, in areas such as climate health, homelessness, and dementia. While the program remains fully funded, the funds would be provided later than initially anticipated including $65 million in both 2024-25 and 2025-26.
Fails to include Additional Funds for Enforcement of Health Plan Data Equity: Both Covered California and the Department of Health Care Services are requiring their contracted health plans to achieve National Committee for Quality Assurance (NCQA) Health Equity Accreditation (HEA) by 2023, or 2026, respectively with California’s Public Employee Retirement System (CalPERS) which manages health and pension benefits for more than 1.5 million public employees, retirees and their families, expected to align as well. Funds should be set aside to guarantee state enforcement of these critical data equity standards.
Reduces Home- and Community-Based Services (HCBS) Spending Plan to $2.8 billion: This is a $60 million cut compared to the 2022 Budget Act for Medicaid beneficiaries to receive services in their own home or community. The Budget assumes that all HCBS spending plan funding will be expended by March 2024, and California will not use the additional optional year to spend the enhanced federal funding. The 2021 Budget Act appropriated funding made available pursuant to the American Rescue Plan Act of 2021 to enhance, expand, and strengthen Home and Community-Based Services for 26 initiatives across six Health and Human Services departments.
Specific Immigrant Programs
Delays Investment to Expand Food4All: While the Governor’s Budget did not cut from earlier investments to expand the California Food Assistance Program (CFAP) to undocumented Californians (ages 55 and above), the Administration has proposed to delay implementation of Food4All to January 1, 2027. This delay will mean thousands of elderly Californians, who need food assistance now, will not have access simply because of their immigration status.
Fails to Include Unemployment Benefits for Immigrant Workers: The Governor’s Budget failed to include investments that would establish the SafetyNet4All Program, and provide undocumented immigrant workers with an alternative, barrier-free option to seek unemployment benefits. This is a critical missed opportunity to support all workers in California, regardless of immigration status.
Migration, Border Communities, and Wraparound Services: The Administration will continue to work with the federal government to identify resources and assess state needs to expand humanitarian efforts to those seeking refuge and asylum in California. With no new investments for border communities or legal services, the Governor’s Budget misses a critical opportunity to support refugees and asylum seekers.
Human Services
- Makes Additional Investments to Increase CalWORKS Grants ($87 million in 2023-24 funded by the 1991 Local Revenue Fund): The Governor’s Budget projects a 2.9% increase in CalWORKS payment levels, specifically Maximum Aid Payments, in 2023-2024. Additionally, given the increase in CalWORKS and EBT electronic thefts over the last years, California will become the first state in the nation to use enhanced security features and technology advancements to safeguard Californians and their benefits.
- Supplemental Security Income/State Supplementary Payment (SSI/SSP) ($146 million General Fund in 2023-24 and $292 million ongoing): The Governor’s Budget reflects increased investments to support additional SSP dollars starting January, 1, 2024. This increase will provide seniors and individuals with disabilities with opportunities to receive increased supplemental support dollars.