The 2018-19 Budget

California Spending Plan (Final Version)

Chapter 2: Spending by Program Area

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Health

Overview of Spending

The spending plan provides $25.4 billion General Fund for health programs. This is an increase of about $2.9 billion, or 13 percent, compared to the revised 2017‑18 spending level, as shown in Figure 13. This year‑over‑year net increase is primarily due to significant growth in projected General Fund spending in Medi‑Cal. To a significant degree, increased projected General Fund spending in Medi‑Cal in 2018‑19 reflects a shift in costs to the General Fund from other state and federal fund sources, rather than an overall increase in program costs. In addition, and as shown in Figure 14, year‑over‑year growth in health program spending reflects a number of policy actions adopted by the Legislature as part of the 2018‑19 spending plan. We discuss these policy actions in greater detail below.

Department of Health Care Services (DHCS)—Medi‑Cal

Overview. The spending plan provides $23 billion from the General Fund for Medi‑Cal local assistance expenditures through DHCS. This is an increase of $2.6 billion (13 percent) compared to the revised estimates of 2017‑18 spending levels. Revised 2017‑18 spending is $830 million (4 percent) above the 2017‑18 Budget Act appropriation, reflecting various technical adjustments that both increase and decrease spending. Of note, spending in 2017‑18 is higher by $680 million General Fund to backfill claims for federal Medi‑Cal funding that the federal government now disputes. We provide more information on General Fund costs associated with these disputed claims below. Growth in Medi‑Cal funding in 2018‑19 over revised 2017‑18 levels primarily reflects (1) reductions in the amount of other state funds available to offset General Fund spending, including funding provided through Proposition 56 (2016); (2) various technical adjustments—largely one time in nature—as a result of reduced federal funding, requiring a General Fund backfill; and (3) regular growth in program costs. We discuss some of the major Medi‑Cal components of the 2018‑19 budget package below.

Proposition 56 Spending Package. Proposition 56, approved by voters in 2016, raised state taxes on tobacco products and dedicates the majority of its associated revenues to Medi‑Cal. The spending plan allocates up to $1.26 billion in Proposition 56 revenues to be spent in Medi‑Cal in 2018‑19 on the following purposes:

• Up to $821 Million for Provider Payment Increases. On a one‑time basis, the spending plan extends the 2017‑18 provider payment increases into 2018‑19 and provides for additional provider payment increases. Budget language directs DHCS to develop the structure for the new 2018‑19 provider payment increases before October 2018 and authorizes DHCS to make 2018‑19 payments available while federal approval of federal funding for the payments is pending (provided that any payments not approved by the federal government can be recouped from providers). Figure 15 summarizes the Proposition 56‑funded provider payment increases included in the spending plan.
• $220 Million to Establish the Proposition 56 Medi‑Cal Physicians and Dentists Loan Repayment Program. On a one‑time basis, the spending plan allocates $220 million in unspent 2017‑18 Proposition 56 funding for Medi‑Cal to establish a loan repayment program for physicians and dentists who participate in Medi‑Cal. We provide additional detail on this program in the “Health Care Workforce” section of this report.
• $218 Million to Offset General Fund Spending on Medi‑Cal Cost Growth. The spending plan dedicates $218 million in Proposition 56 revenue to offset General Fund spending in Medi‑Cal. This represents a decrease from the $711 million in Proposition 56 revenue that offset General Fund spending in Medi‑Cal in 2017‑18. The reduced Proposition 56 General Fund offset accounts for nearly $500 million of the year‑over‑year $2.6 billion increase in General Fund Medi‑Cal spending between 2017‑18 and 2018‑19.

Repayment of Federal Funds Received for Potentially Disallowed Claims. The spending plan includes $754 million General Fund in 2017‑18 and $675 million General Fund in 2018‑19—a total of $1.4 billion over the two years—to replace a projected loss in federal funds related to an increased amount of claims the federal government now disputes. Until such disputes are resolved, the federal government requires the state to return previously claimed federal funds. To ensure Medi‑Cal is fully funded, the state must backfill the lost federal funds with General Fund. The state will likely be able to eventually recover a significant portion of this funding (resulting in General Fund savings) by submitting required supporting documentation for the disputed claims, but the amount and timing for recovering funds is unknown.

Federal Reauthorization of Funding for the Children’s Health Insurance Program (CHIP). The spending plan reflects $600 million less General Fund support for Medi‑Cal in 2018‑19 relative to the Governor’s January budget as a result of the federal reauthorization of funding for CHIP. In January, the Governor’s budget assumed federal funding for CHIP would be reauthorized at a 65 percent federal share of cost—a lower share of cost than the 88 percent federal share of cost the state had previously been receiving. (A lower federal share of cost corresponds to higher General Fund costs for CHIP.) The February 2018 federal reauthorization of CHIP funding temporarily maintains the federal share of cost at 88 percent through state fiscal year 2018‑19, reducing projected state spending compared to the Governor’s proposed January budget. For more information on the impact of the federal reauthorization of CHIP on state Medi‑Cal spending, please see our Budget and Policy Post: Recent Congressional Action on the Children’s Health Insurance Program (CHIP).

Provides for a Cost‑of‑Living Adjustment (COLA) for County Administrative Funding. The budget includes $28 million General Fund ($56 million total funds) to provide a COLA to county funding for Medi‑Cal eligibility determination activities. The budget also assumes the continuation of county administrative funding augmentations that began in 2013‑14 and grew in subsequent years to reflect increased Medi‑Cal caseloads following the implementation of the Patient Protection and Affordable Care Act.

Expands Availability of Hepatitis C Treatment. The spending plan provides $22 million in General Fund to expand the availability of potentially curative Hepatitis C prescription drugs to almost all Medi‑Cal enrollees with the disease. Until 2018‑19, only Medi‑Cal enrollees with a relatively advanced stage of Hepatitis C, as well as enrollees with certain related conditions, generally qualified to receive the curative prescription drug treatments. A full course of these treatments costs tens of thousands of dollars, though the cost of the drug treatments has declined in recent years. As a part of the May budget proposal, the Governor proposed, and the Legislature approved, expanding the availability of these drug treatments across multiple state‑funded health care programs, including Medi‑Cal, Correctional Health Care Services, and the Department of State Hospitals. With the augmentation, DHCS will update its clinical guidelines for Medi‑Cal to make the drug treatments available to all patients age 13 and above with Hepatitis C, except for those with life expectancy of less than 12 months.

Establishes San Mateo Dental Integration Pilot Program. Budget‑related legislation grants DHCS the authority to establish a dental integration pilot program in San Mateo County no sooner than July 2019, provided the Legislature appropriates funding at a future time. Currently, Denti‑Cal—Medi‑Cal’s dental program—is provided on a fee‑for‑service basis in San Mateo as well as throughout most of the state. Under the pilot program, the Health Plan of San Mateo would become responsible for the delivery and financing of Denti‑Cal services. This pilot program would represent the first time a Medi‑Cal managed care plan that oversees the broader physical health of Medi‑Cal enrollees is made responsible for its members’ dental care.

Removes Limits on Treatment Length in the Breast and Cervical Cancer Treatment Program (BCCTP). The BCCTP provides breast and cervical cancer treatment for individuals with incomes below 200 percent of the federal poverty line who do not have alternative low‑cost treatment coverage. For certain individuals in BCCTP that do not qualify for full‑scope no‑cost Medi‑Cal coverage, prior law limited treatment to between 18 months (for breast cancer) and 24 months (for cervical cancer). Legislation adopted as part of the budget package eliminates these limits on treatment length. The budget provides $8.4 million from the General Fund in 2018‑19 for this change.

Provides Funding for the Development of Health Information Exchanges (HIEs). The 2018‑19 budget includes $5 million General Fund (one time) to expand the use of HIEs among safety net health care providers. HIEs serve as platforms for providers and health care plans to access and share their patients’ and members’ electronic health records. This state funding is expected to leverage $45 million in federal American Recovery and Reinvestment Act funds. The spending plan gives DHCS broad flexibility to determine how to administer this funding.

Establishes Whole Genome Sequencing Pilot Project. The 2018‑19 spending plan provides $2 million General Fund to establish a Medi‑Cal Whole Genome Sequencing Pilot Project. The funding will be allocated through a grant to a nonprofit organization in the state, yet to be determined, which will use the funding to investigate the potential value of using whole genome sequencing to help in the diagnosis and treatment of Medi‑Cal patients, especially children with complex medical needs.

Provides Funding for Additional Data Collection Through California Health Interview Survey (CHIS). The budget includes $3.8 million General Fund ($7.5 million total funds) on a one‑time basis to collect additional information through CHIS, a statewide health survey administered by the University of California (UC) Los Angeles. Specifically, the budget includes $3 million General Fund ($6 million total funds) to add questions to CHIS related to the demand for long‑term services and supports among seniors and persons with disabilities in the state. The remaining $750,000 General Fund ($1.5 million total funds) augmentation is to test new ways of collecting health information from children and youth.

Extends Pediatric Mobile Optometry Services Funding for a Half Year. The spending plan provides up to $1 million General Fund to extend state funding for a pilot program that provides mobile optometry services to school children in Los Angeles County. Under this program, optometry services, including vision examinations and the providing of eyeglasses, are provided onsite at schools. This funding will extend payments for these services for the period from July 1, 2018 to December 31, 2018, after which the program will sunset.

Health Care Workforce

The spending plan provides significant one‑time funding to expand the state’s health care workforce and improve its geographic distribution across the state. Below, we describe the health care workforce augmentations in the 2018‑19 spending plan.

Establishes the Proposition 56 Medi‑Cal Physicians and Dentists Loan Repayment Program. As previously noted, the spending plan dedicates $220 million in one‑time Proposition 56 Medi‑Cal funding to establish a medical and dental school student loan repayment program for recent graduate physicians and dentists that participate in Medi‑Cal. This funding, with $190 million to physicians and $30 million to dentists, will be available for expenditure through 2024‑25. Budget legislation establishing the program directs DHCS to develop the criteria governing who can receive funding through the loan repayment program as well as the award amounts. The legislation directs DHCS to prioritize ensuring timely access, limiting geographic shortages of services, and ensuring quality care in Medi‑Cal in the design of the program.

Augments UC Graduate Medical Education (GME) Programs. The spending plan dedicates $55 million General Fund (one time) to UC for GME programs. Of this funding, $40 million will support residency programs for primary care, emergency, and potentially specialist physicians. The remaining $15 million is for the UC Riverside School of Medicine for psychiatric residency programs which currently incorporate telemedicine into their practice or plan do to so in the future. This $15 million in funding is available for expenditure until June 30, 2023.

Dedicates State Mental Health Services Act Funding to Mental Health Workforce Programs. The spending plan includes $11 million (one time) from the Mental Health Service Fund (MHSF) to expand the state’s mental health workforce. Of this funding, $10 million will provide additional funding to the Office of Statewide Health Planning and Development (OSHPD) for the mental health Workforce Education and Training (WET) program. State funding for WET had largely been set to expire at the end of 2017‑18. The remaining $1 million, also through OSHPD, will fund scholarships for primary care and emergency physicians participating in psychiatry fellowships at either the UC Davis Medical School or the UC Irvine Medical School.

Provides Funding to Increase the Number of Certified Nursing Assistants (CNAs). The spending plan provides $2 million from the General Fund (about $5 million in total funds) in response to new staffing requirements at skilled nursing facilities (SNFs). Absent any action to increase the number of CNAs in the state, the administration estimated a shortfall of about 1,400 CNAs by July 1, 2018, when the new rules take effect.

Health Care Coverage and Affordability

Through the development of the 2018‑19 budget package, the Legislature considered a variety of proposals to expand health care coverage and improve the affordability of coverage. The 2018‑19 budget package includes the following actions related to these issues:

• Establishes an All‑Payer Health Care Cost and Utilization Database. The budget provides $60 million General Fund on a one‑time basis to OSHPD to establish a database that would collect information on public and private health care costs and utilization in the state. The database is intended to be used to increase the transparency of health care pricing and inform state policy decisions. Budget legislation directs the creation of a stakeholder committee to advise on the establishment and ongoing maintenance of the database, and outlines the intent of the Legislature that the database be completed by July 2023.
• Creates a Council on Health Care Delivery Systems. The spending plan provides $5 million in General Fund for the Health and Human Services Agency to establish a task force whose goal is to develop options for accomplishing universal health care coverage and reducing health care costs. The council will be composed of appointees of the Governor, Senate, and Assembly, and will submit a report to the Legislature on available options by October 1, 2021.
• Directs California Health Benefit Exchange to Produce a Report on Improving Individual Market Affordability. Budget legislation directs the state’s health benefits exchange, known as Covered California, to develop options for providing additional financial assistance to low‑ and middle‑income residents to promote access to health insurance coverage. The legislation requires Covered California to report to the Legislature, Governor, and Council on Health Care Delivery Systems, regarding these options no later than February 2019.

Behavioral Health

Repays Counties for Outstanding State Mandates Related to Children’s Mental Health Services. The spending plan includes $281 million from the General Fund to repay counties, with interest, for costs incurred for state mandates related to services for children with mental illness. Counties incurred these costs to implement AB 3632 mandates, which assigned responsibility for mental health services for special education students to county mental health agencies. The county mandates were repealed when Chapter 43 of 2011 (AB 114, Committee on Budget and Finance) transferred this responsibility to schools.

Establishes One‑Time Homeless Mentally Ill Outreach and Treatment Grant Program. The spending plan provides $50 million on a one‑time basis from the General Fund for DHCS to distribute grants to counties to fund multidisciplinary teams providing outreach, treatment, and related services for homeless persons with mental illness. Grant determinations will be made by DHCS in consultation with the Department of Finance (DOF) and the California State Association of Counties based on a county’s number of homeless persons with mental illness and its overall population. Counties receiving grants are required to report the use of funds, services provided, and the number of individuals served to DHCS. The funds will be available through 2019‑20 and are intended to provide bridge funding prior to the implementation of other programs targeted at homeless persons with mental illness, such as the No Place Like Home program.

FundsAll Children Thrive Pilot Program. The spending plan provides $10 million one time, available over three years, for DPH from the MHSF for a three‑year pilot program to study and report on childhood trauma and associated local interventions, with particular attention to racial equity and community involvement and resilience within high need cities and counties.

Provides Ongoing Funding for Suicide Hotlines. The spending plan includes $4.3 million in ongoing MHSF funding to allow the state’s 11 crisis call centers that answer calls through the National Suicide Prevention Lifeline to maintain services that were originally funded with discretionary county MHSF funds. The ongoing funding resolves a recurring suicide hotline funding shortfall that in previous years was addressed with one‑time MHSF state administrative funding.

Reduces Ongoing Funding for Mental Health Crisis Response Personnel Grants. In 2013‑14, the Legislature established a grant program administered by the Mental Health Services Oversight and Accountability Commission (MHSOAC) that provides counties with funding to hire “triage” personnel to assist with mental health crisis response, stabilization, and treatment. The Legislature has appropriated $32 million in MHSF annually for the program since its inception. After several consecutive years in which funding for the program was not fully expended, the spending plan reduces ongoing funding for this program to $20 million annually. To provide funding in 2018‑19, the spending plan reappropriates $20 million in unspent funding for triage grants from 2017‑18.

Expands Consumer Advocacy Contracts to Include Immigrant and Refugee Populations. The spending plan includes $670,000 ongoing MHSF funding for the MHSOAC to develop consumer advocacy contracts with non‑profit organizations that do outreach, education and training, and advocacy related to mental health outcomes among immigrants and refugees. This augmentation doubles funding for MHSOAC advocacy, which currently has programs supporting organizations that work with various other targeted populations, including: children; veterans; and lesbian, gay, bisexual, transgender, and queer communities, among others. The augmentation is designed to address concerns about access to mental health care services by immigrant and refugee communities.

Department of Public Health (DPH)

The spending plan provides $3.21 billion from all fund sources for DPH programs, up 2 percent from $3.16 billion in 2017‑18. Of the total, General Fund spending accounts for $175 million, an increase of 17 percent from $150 million in 2017‑18. Most of the year‑over‑year increase in General Fund spending results from augmentations by the Legislature. As detailed below, some of the increases fund programs and services, while others support research and outreach. (In the “Other Provisions” section of this report, we describe augmentations related to cannabis regulation, including an increase of $10.6 million from the Cannabis Control Fund for DPH’s role in licensing and regulating cannabis manufacturers.)

Public Health Programs and Services. The spending plan provides about $25 million from the General Fund for the following programs:

• Amyotrophic Lateral Sclerosis (ALS) System of Care. $9 million one‑time General Fund, available over three years, to support wrap‑around services for individuals with ALS.
• Black Infant Health Program. $8 million ongoing General Fund to expand the Black Infant Health Program, which seeks to reduce black‑white disparities in infant and maternal health, by providing funding to 15 counties to establish local grant programs. These programs will promote the development of Community Centers of Excellence in perinatal health and promote evidence‑based or evidence‑informed prenatal care, family planning, and fatherhood initiatives.
• HIV/AIDS and Sexually Transmitted Disease (STD) Services and Prevention. $5 million one‑time General Fund augmentation for comprehensive HIV prevention services including pre‑exposure prophylaxis (PrEP) and post‑exposure prophylaxis (PEP), and a $2 million one‑time General Fund augmentation for STD prevention. (The spending plan also provides $2.7 million ongoing from the AIDS Drug Assistance Program [ADAP] Rebate Fund to expand DPH’s Office of AIDS eligibility and enrollment activities and $2 million ongoing from the ADAP Rebate Fund to expand eligibility for PrEP and PEP.)
• Contaminant Testing Guidelines at Public Beaches. $354,000 in 2018‑19 from the General Fund to finalize implementation of contaminant testing guidelines at public beaches. (The General Fund will also provide decreasing amounts for this purpose through 2022‑23.) Funding will allow DPH to complete development of rapid testing protocols and finalize guidelines pursuant to Chapter 928 of 2014 (SB 1395, Block).
• Border Health Efforts. $300,000 ongoing General Fund to backfill the loss of federal funds for health‑related efforts in border communities near Mexico.

Public Health Research and Outreach. The spending plan provides $10.6 million General Fund for public health‑related research and outreach. (It also provides $10 million one time from the Mental Health Services Fund for the “All Children Thrive” pilot program to study local interventions to prevent and treat childhood trauma, as noted in the “Health” section of this report.) The funds will support:

• Valley Fever Research and Outreach. $2 million one‑time General Fund, available over two years, for education and outreach on valley fever and $3 million General Fund one time for valley fever research at Kern Medical Center in Bakersfield. (In addition, the spending plan includes $3 million one‑time General Fund for valley fever research at the University of California.)
• Alzheimer’s Disease Program Grant Awards. $3.1 million ongoing General Fund (and $104,000 one time from the California Alzheimer’s Disease and Related Disorders Research Fund) to provide grants for Alzheimer’s research.
• Diabetes Outreach Awareness Campaign. $2.5 million one‑time General Fund, available over two years, to implement a diabetes prevention and treatment awareness campaign.

Capital Outlay at Richmond Lab. The spending plan provides $4.9 million from the General Fund for the Richmond Viral and Rickettsial Diseases Laboratory Bio‑Safety Level 3 upgrade. Funding will allow DPH to complete working drawings and construction costs of the upgrade.

Proposition 56 Revenues. The spending plan provides $165.5 million from Proposition 56 tobacco tax revenues for three DPH programs, as specified by the language of Proposition 56:

• $129.5 million for the Tobacco Control Branch for its tobacco prevention efforts.
• $30 million for the state dental program.
• $6 million for tobacco law enforcement efforts, specifically DPH’s Stop Tobacco Access to Kids Enforcement Program.

Special Fund Augmentations. In addition to the General Fund augmentations described above, the spending plan also provides $35.4 million in increased expenditure authority from special funds for DPH. Major augmentations include one‑time funding for the licensing and regulation of cannabis manufacturers ($10.6 million) and a pilot project related to childhood trauma ($10 million).

Department of State Hospitals (DSH)

Under the budget plan, General Fund spending for DSH will be about $1.7 billion in 2018‑19, an increase of $192 million, or 12 percent, from the revised 2017‑18 level. The year‑over‑year net increase is largely due to the establishment of Incompetent to Stand Trial (IST) diversion programs and activation of additional treatment capacity, as discussed below.

IST Diversion Programs. The budget provides a one‑time $99.5 million General Fund augmentation for DSH to contract with counties to establish IST diversion programs. The budget package includes legislation to authorize trial court judges to refer certain individuals who are likely to be found IST or have been found IST into treatment programs supported by these funds rather than referring them to a state hospital. If such individuals successfully complete these programs, judges could drop or reduce the charges against the individuals. In order to receive funding, counties must submit program plans to DSH and the Council on Criminal Justice and Behavioral Health for review and approval. Large counties are required to contribute 20 percent towards the cost of operating a diversion program, while small counties are required to contribute 10 percent.

Additional IST Treatment Capacity. The budget provides an $51.2 million General Fund augmentation to expand IST patient treatment capacity. This includes (1) $28.5 million (increasing to $72.6 million annually by 2021‑22) to activate and staff 236 beds at DSH‑Metropolitan, (2) $13.1 million to establish a community‑based IST treatment program in Los Angeles County, and (3) $9.6 million to establish additional county jail‑based competency treatment program beds.

Other Adjustments. The budget also provides $11.5 million (General Fund) for the activation of 80 beds for mentally disordered offenders at DSH‑Coalinga. In addition, the budget includes $9.4 million for the construction phase of a project to upgrade the DSH‑Patton Fire alarm system and $3.3 million to treat additional patients with Hepatitis C.

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