Senate Select Committee Older Lgbtq Californians

Senator Padilla. Thank you, Mr. Chair. Appreciate your leadership in this space, your long leadership in this building, and working to convene the select committee on this topic, one that is more than timely. Honored to join some esteemed colleagues here. Honored to be hearing from the panelists. And I think, you know, all good intentions produce good results, but some of them unanticipated. So we have wonderful advances in technology and medical care, and we have aging populations. that at one point, sadly, were not expected to age. And so as a community, we have in part a scenario that we wished for but have not been prepared for. So it is a joyous burden in some ways, and I look forward to the dialogue here to be thinking about ways that, as a matter of policy and other priorities, we can address the needs in the community. And, again, I thank the chair. Thanks again for being here.

Thank you so much. And I also just want to express immense gratitude, certainly to all the panelists, and particularly to the chair, who is at every stage of his own career and life has been taking on these challenges. If there was a select committee on middle-aged LGBTQ Californians, he would have been leading that. Young ones as well. And, you know, in preparation for the hearing, I was reading a couple of sort of intergenerational studies by academics in the field and about sort of the even older generations than we've talked about today and their comparisons to sort of the generation before, what you might call the silenced generation and the invisible generation even before that from the 20s on. And what really struck me was that these are generations with far that enjoyed far fewer if any rights at all recognition safety security much of what we increasingly take for granted as the chair noted but that this generation, what's in these studies referred to as the pride generation, the 60s and 70s and 80s, with more of those rights and safety and supports, but more challenged mental health outcomes, more challenged physical health outcomes despite that. And so this isn't, for me, the hearing is not just about how do we say thank you to folks who blazed a trail But folks who have paid a bitter price in terms of more intense trauma and struggle that has led to the progress that the chairs outlined that they continue to grapple with. And then to some extent, and the nursing home example is the greatest one of these, is that where they are, in many cases, they, we, are still in some sense living in the 70s or the 80s or the 60s, even despite the changes in laws and programs and what have you. And so this hearing could not be more timely and more profound, and I really want to, as I say, salute the chair for your work in fighting so hard to assure that this committee and this was foreign that the spotlight has shined. Thank you.

Good afternoon, Chair Laird and select committee members. Denny Chan on behalf of Justice and Aging. We're a national legal advocacy organization dedicated to strengthening the rights of low-income older adults, including LGBTQ older adults. Thank you for conducting today's inaugural hearing on health and supports for LGBTQ older Californians. Across the state, somewhere between 120,000 to 400,000 older Californians identify as LGBTQ+, and these numbers continue to grow. As they age, they face significant inequities and discrimination in many areas. In California's first-ever survey of LGBTQIA plus older adults from 2024, 27% of respondents reported being treated unfairly, with less respect than others, or discriminated against in just the past 12 months. And keep in mind, that was from 2024, so that may have even changed or increased today. In the same survey, almost one in four reported incomes of less than $400,000. dollars. LGBTQ older Californians experience significant challenges with respect to health and health care coverage. As they age and their health needs grow, they need more help. Nearly a quarter of respondents describe their physical health as fair or poor and notably and I get back to this point in just a minute notably almost one in ten reported difficulty doing errands alone and it was even higher for respondents of color and transgender individuals Given these health needs and their economic insecurity, the Medi-Cal program is an important lifeline for LGBTQ older adults here in California. Across the country, LGBTQ adults are twice as likely as their non-LGBTQ counterparts to have Medicaid as their primary source of health care coverage. This is particularly important for LGBTQ older adults who are not yet Medicare eligible, like people between 50 and 64, because they have no other source of coverage. Medi-Cal enables LGBTQ older adults to have access to essential health and long-term care to age with dignity. While many of them may also qualify for Medicare, the Medicare program alone is inadequate to meet their needs. Medi-Cal helps pay for Medicare premiums and cost sharing. Medi-Cal is the primary funder for home and community-based services, ranging from personal care aides who help older adults with their daily activities, like our IHSS program, to home modifications that help them move around in their homes independently. Medi-Cal also pays for other optional services like vision, hearing, and dental. This is particularly important for LGBTQ older adults because they disproportionately rely on Medi-Cal funded home and community-based services. They're less likely to have traditional sources of unpaid care from family. LGBTQ older adults are twice as likely to be single and four times less likely to have children those are the people who would provide unpaid care so Medi-Cal home and community-based services can fill that gap unfortunately as a result of the passage of HR1 from last year cuts to Medicaid will have a significant impact on older adults especially LGBTQ older adults in California cuts to Medi-Cal lead to reduced state budgets and ultimately cuts to critical programs like home and community-based services. Senator Laird, this goes back to your point because this would increase the likelihood of LGBTQ older adults being institutionalized where they face unique discrimination and can be forced to go back in the closet. These cuts will also result in reduced provider reimbursement, further limiting the number of providers who can provide culturally competent care to LGBTQ older adults in the state. The fallout from H.R.1 collides with the Trump administration's ongoing assault of LGBTQ communities across the country. From executive order to agency action, the federal administration has used all of its tools to make life more difficult for LGBTQ older people, rolling back policies that target LGBTQ communities, attacking gender-affirming care for minors, and erasing data for transgender individuals, all in the name of reversing diversity, equity, and inclusion efforts. Back home here in California, the state government has been unfortunately slow to respond to the erosion of rights at a federal level. For example, in the 2025-2026 California Master Plan on Aging Initiatives, of the 81 initiatives, only two mention LGBTQ older people, one of which is to conduct outreach and focus groups to improve access and build upon the state's survey. These actions are inadequate, given the threats to LGBTQ older adults. Now is the time for state departments like the California Department of Aging and the Department of Health Care Services to use all of its tools and double down on their commitment to LGBTQ older people and ensure that through policy and action, they can age with dignity and justice. Thank you for this opportunity and happy to answer questions at the appropriate time.

Thank you. Good afternoon, Chair Laird and members of the Select Committee. My name is Brian Kaplan, and I serve as the Deputy Secretary for Policy and Strategic Planning at the California Health and Human Services Agency. Thank you for the opportunity to address the Select Committee about our work to support LGBTQ plus older Californians. It is my distinct privilege to provide an overview of CalHHS in our departments, as well as the efforts underway to support these older adults, who are a significant focus for the administration and for our programs. California is leading the way in creating a future where every older adult, including those who are LGBTQ+, is valued, respected, and supported. Despite federal threats to the LGBTQ plus community and the impact of federal actions such as HR1 on the healthcare system and social safety net, California continues to lead the way and fight for the health and well-being of its communities, including LGBTQ plus older adults. You will soon hear from three of our departments, aging, public health, and social services, each speaking to their work in this area. I will also share a few points on behalf of the Department of Health Care Services, which is unable to participate in today's hearing. Cal HHS is composed of 12 departments and four offices dedicated to improving the health and well-being of all Californians through the administration and oversight of a number of health, behavioral health, and social services programs. Our mission is to work together with counties, cities, and communities, as well as our public, private, faith, and educational partners to make California a healthy, vibrant, inclusive place to live, play, work, and learn. Central to that mission is ensuring that our older adults are supported in every community and every setting of care. By 2030, just a few years from now, nearly 10 million Californians will be six years of age or older, representing almost 25 percent of the state's population. Between five and ten percent of these individuals identify as LGBTQ+. In January of 2021, the Newsom administration released the Master Plan for Aging, a comprehensive commitment to California's older adults, people with disabilities, and caregivers. The MPA is a 10-year blueprint for public and private partners to plan for the state's shifting demographics and to ensure that this community is represented and served appropriately. As part of the MPA, the state conducted the first-ever statewide survey about the current and future health and well-being of LGBTQ plus midlife and older adults. While 86% of survey respondents reported overall positive well-being with quality of life rated as good or very good, there are key indicators in the data about subgroup health disparities, social isolation, and discrimination that are critically important to address. In the LGBTQ plus community, ensuring that we address belonging and isolation for older adults, as well as stigma and discrimination, is vitally important. You will hear more from the Department of Aging in this hearing on the MPA and on these survey results. These critical findings provide a foundation for meaningful change, guiding our advancement of the MPA, and ensuring that all older Californians feel recognized and included. You will also hear from CDSS on supporting older adults in our social services programs, one of the key ways we are effectuating the MPA. And finally, you will hear from the Department of Aging and the Department of Public Health on their work to support older adults living with HIV, including through the Area Agencies on Aging and a number of CDPH-administered programs. supporting the needs of older adults living with HIV is of particular importance. As the Chair noted according to the Centers for Disease Control and Prevention more than half of people living with HIV are over the age of 50 with a unique set of health and equity challenges to address First and foremost Cal HHS and its departments are committed to supporting and honoring the dignity of our LGBTQ plus community members, including older adults. California state law prevents discrimination on the basis of sexual orientation and gender identity, and we are dedicated to ensuring that older Californians can thrive and access the care they need, free from discrimination. In particular, DHCS supports and ensures access to medically necessary evidence-based gender-affirming care as a covered benefit for Medi-Cal members, in alignment with state law and our mission to promote the health and well-being of all Californians. Gender-affirming care refers to services provided to address incongruence between a Medi-Cal member's 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. Medi-Cal managed care plans may not deny or limit care based on a member's gender identity. Coverage decisions must solely rely on medical necessity consistent with clinical guidelines. DHCS has also issued various all-plan letters to managed care plans in the last few years to reinforce these policies. You will hear more about federal impacts in the coming panels, but recent federal actions attempting to restrict access to gender-affirming care disregard established, peer-reviewed research showing that this care is effective, medically necessary, and improves health outcomes. These proposed federal actions do not yet carry the force of law and California law protecting access to gender-affirming care remains fully in effect. I will now share a little bit about a few selected programs and services that DHCS administers to support older Californians. The Program for All-Inclusive Care for the Elderly, or PACE, integrates Medicare and Medi-Cal benefits to keep eligible older adults living safely in the community rather than institutions. PACE participants get all Medicare and Medi-Cal covered services through one organization, coordinated by an interdisciplinary team or IDT and anchored by a PACE center. This integrated care, managed through the IDT, reduces fragmentation and improves continuity, especially important for LGBTQ plus older adults who may have experienced discrimination or inconsistent care. The IDT tailors each PACE participant's care plan to their identity, goals, and social context, which is essential for LGBTQ plus older adults who may have unique health histories and care preferences. Of note, in September 2024, DHCS implemented the Gender Affirming Care Policy Letter, which is tied to Senator Weiner's Senate Bill 923. This letter directs base organizations and directed entities to require staff to complete evidence-based cultural competency training for the purpose of providing inclusive health care to individuals who identify as transgender, gender diverse, or intersex. In addition, older adult Medi-Cal members have access to a wide range of care management services directly through MCPs. These services include an initial needs assessment with linkage to appropriate long-term services and supports and to care management programs such as enhanced care management and transitional care services. Medi-Cal MCP members also have access to community supports such as medically tailored meals and housing navigation services to help them thrive while maintaining independence living in the community. Many LGBTQ plus older adults may not have family to care for them, so it is incumbent on our programs to support them comprehensively in every setting of care. Thank you again for the opportunity to address this committee on our work to support LGBTQ plus older Californians. As we face an uncertain federal landscape, California's commitment to this community has never been more important. We look forward to continued engagement and partnership with you to ensure that California remains a place where every older adult can thrive. Thank you.

Good afternoon Chair Laird and members of the Senate Select Committee My name is Sarah Steenhausen and I serve as Deputy Director of the Department of Aging Division of Policy Research and Engagement and I really appreciate the work that you have done to uplift this issue in this population through this committee. From Harvey Milk to the AIDS crisis to marriage equality, older LGBTQIA adults didn't just witness history, they made it. Older LGBTQIA adults are not just a legacy, but they are the leaders, the mentors, and the advocates whose lived experience helps shape policy today. But this appreciation must come with responsibility, as too many LGBTQIA older adults face isolation, housing insecurity, and barriers to affirming health care. So what I'm going to do today is provide an overview of the findings of our first statewide study on older adults. You've heard referenced earlier, but also an update on the implementation of our Master Plan for Aging. So as you know, Governor Newsom launched the Master Plan for Aging in 2021. So now we are in year six of implementation. and in partnership with our state and public and private partners, we continue to advance the MPA's five bold goals, including one, housing for all ages and stages, two, health reimagined, three, inclusion and equity, not isolation, four, caregiving that works, and five, affording aging. I want to note that the plan intentionally uplifts equity across all five bold goals, and in particular, the population of LGBTQIA older adults and those living with HIV continues to be a priority. And despite the devastating impacts of HR1 and the continued federal threats to our most vulnerable communities, we continue to uphold California values and priority populations in alignment with the Master Plan for Aging. I will now discuss the impetus for and provide an overview of the first statewide study on LGBTQIA older adults. It's been said that by 2030, nearly 10 million Californians will be 60 years of age or older, and researchers cite that approximately 5 to 10 percent of this population are part of the LGBTQIA community. Yet we know relatively little about the health and well-being of this community. So to begin filling these gaps, the Department of Aging spearheaded the first statewide survey of midlife and older LGBTQIA adults to better understand the health and well-being and to inform implementation of the Master Plan for Aging. We view this as a baseline survey that can be built upon in future years. As part of this effort, the department worked with subject matter experts and academic partners in the survey design, data collection, and issues impacting this community. Additionally, a community advisory committee provided input on the overall survey design and dissemination. To support language access, the survey was translated into Spanish, Chinese, and Tagalog. We received over 4,000 survey respondents, including responses from every census region in the state, representing a range of sexual orientations and gender identities, as well as diverse racial and ethnic groups. In the final analysis survey respondents generally skewed more white higher income more educated and more urban So it important to note that Additionally a series of focus groups discussions were held across the state to provide individual perspectives and more depth to the survey findings 23 focus groups were held with over 200 underrepresented LGBTQIA older adults who are the hardest to reach and often excluded from these types of surveys. Focus groups participants included low-income, marginalized, and geographically isolated individuals. I'm now going to walk through the key findings, of which there are five that I want to highlight. Key finding one is strong resilience but unequal outcomes. Many survey respondents report overall positive well-being with 86% rating quality of life as good or very good. However, significant disparities exist for certain subpopulations. For example, there were worse outcomes reported for transgender older adults and older adults of color. And in the focus groups, participants consistently described lifelong resilience in the face of discrimination. The second key finding is centers on health care access and trust barriers. Both the survey respondents and the focus group's findings show that many LGBTQIA older adults have experienced significant lifetime trauma and discrimination, including in family, employment, housing, and health care settings, with nearly half of survey respondents having experienced a traumatic event in their lifetime. Additionally, concerns about discrimination in care settings persist into older age. In the focus groups, participants described avoiding or delaying care due to fear of mistreatment with a strong emphasis on needing to explain identity repeatedly in clinical settings. The third key finding centers on economic security challenges. Over a quarter of respondents reported current and future financial concerns, including income stability, housing security, and benefits navigation. Focus group participants described the difficulty experienced in making ends meet and in navigating complex systems of care. This economic strain directly affects the ability to age and place and access care with dignity. The fourth key finding centers on social isolation. Survey respondents listed social support as one of the top five service categories with the most unmet need. One in five respondents rated their mental health as fair or poor, and 11% reported experiencing serious thoughts of suicide within the past year. These challenges are more pronounced among transgender and gender-expansive respondents, with the highest rates reported among transgender women at 18%. Many of the respondents live alone and lack traditional caregiving structures, as my colleague Denny Chan was speaking to. Therefore, individuals who live alone are at higher risk of social isolation compared to the general population, and there's many issues that stem from social isolation. And finally, the fifth key finding is on discrimination. Across both survey and focus groups, discrimination continues to shape access, trust, and engagement with aging and health systems. Respondents reported discrimination related to sexual orientation, gender identity, as well as other aspects of the population. identity, including age, race and ethnicity, disability status, money and income, and others. Nearly one in five reported experience in abusive or threatening situation in the last year, but the majority, almost 80%, did not report these incidents to authorities. The survey respondents reported widespread reluctance to report safety and discrimination discrimination issues to authorities, as well as discomfort disclosing their gender identity and sexual orientation to professionals who should be sources of help and support. Many of the focus group participants also noted that they're often unsure where to go for affirming support. So in conclusion, the study elevated the importance of strengthening culturally responsive and affirming care across systems, improving access through navigation and outreach, and addressing gaps where services exist but are not visible or trusted by LGBTQIA older adults. Additionally, the findings point to the importance of supporting alternative structures to traditional caregiving structures, including chosen family as caregivers. Finally, improving data collection and standardizing collection of identifiers in aging, health, and social service systems can help ensure that we understand the population needs, the gaps, and the opportunity for service improvements. Thank you for the opportunity to be here, and I'm happy to answer any questions when

Thank you. Thank you, Mr. Chair and members of the committee. My name is David Jax Kelly. I'm the founder, president and CEO of Aging and HIV Institute, and I'm a person aging with HIV. I'm here in an advocate role to frame what we are seeing at a systems level, not just what people experience, but how system design produces these experiences. What I want to focus first on is fragmentation. People often experience this as difficulty navigating care, but what sits underneath that is that aging services, HIV care, and broader health care are structured as separate health systems. They are funded separately, designed separately, and held accountable separately. There is no built-in expectation that these systems coordinate with each other. No shared responsibility for the whole person. So what happens in practice is that individuals become the point of coordination. They carry the burden of navigating across systems that were never designed to work together. What people experience are gaps, delays, repetition, having to tell their story over and over again in different places. But the pattern is consistent. When systems are fragmented, coordination becomes optional. And when coordination is optional, it often does not happen. This is not an individual failure. This is a system design outcome. And it has real consequences. It affects continuity of care. It affects adherence. It affects whether people stay engaged at all. This is especially pronounced for older adults living with HIV who are interacting not just with one system but with multiple systems at once Aging services HIV care primary care behavioral health Without integration, there is no single place where the full picture is held. That is the first issue. The second is invisibility. Fragmentation describes how systems are structured. Invisibility describes what happens when populations are not recognized within those structures. If a population is not explicitly named in planning documents, in data systems, and in policy frameworks, it is not systematically included in how services are designed or delivered. We have seen this in the California State Plan on Aging and the Master Plan for Aging. Historically, older adults have been treated as a general category, without consistent attention to how aging intersects with HIV or LGBTQ plus identity. When that happens, needs are assumed rather than defined. Data is incomplete. Data systems are incomplete and not consistently designed to capture the populations that they are meant to serve. Outreach is not targeted. Services are not designed with those populations in mind. And the result is that people who do not see themselves reflected in the systems that are meant to serve them. This is where visibility with purpose becomes important. Visibility is not about language alone. It is about whether systems are designed to recognize and respond to specific populations. The HIV and Aging Act is a clear example of this principle. When people aging with HIV were explicitly named as a population of greatest social need, it created a basis for inclusion, for data collection, and for accountability. Naming changes outcomes. without naming systems default to generalization, and generalization often leads to exclusion. So fragmentation and invisibility are connected. One describes a structure, the other describes a consequence. I want to briefly ground this in lived experience. When I was first navigating care as a person living with HIV, I found myself moving between different providers and systems that were not connected to each other. I was managing my HIV care in one place, aging-related concerns in another, and broader health care needs somewhere else. At that point, I was responsible for connecting the dots. This experience is not unique. What it reflects is a pattern, and that pattern reflects how these systems are designed. When there is no integrated structure, individuals become the integration point. And that is not a sustainable or equitable model of care. It depends on a person's ability to navigate, to advocate, and to persist, which means the system works best for those with the most capacity and least well for those with the least. That is a design issue. There are additional issues that follow from this. Workforce readiness is one. Providers are not consistently trained to understand the intersection of aging, HIV, and LGBTQ plus identity. Access and continuity is another. People experience disruptions as they move between systems that are not aligned. What is happening at the federal level will either reinforce or undermine these system challenges. Many of the services older adults rely on are supported through federal programs. The Older Americans Act, Medicaid, Ryan White, and housing supports like HOPWA. When those programs face funding instability, policy shifts, or lack of coordination at the federal level, the impact shows up locally as gaps in access disruptions in care and reduced capacity for coordination And for populations that are not explicitly named within these frameworks those impacts are often felt first and most severely So when we talk about fragmentation and invisibility, those are not just state level issues. They are shaped by how federal policy defines, funds, and prioritizes the systems themselves. I do want to make one broader point. Healthcare access does not exist in isolation. For older adults, including those aging with HIV, factors like housing, food, transportation, and economic stability are fundamental determinants of health. But even these factors depend on whether systems are designed to recognize and to respond to the populations they are meant to serve. What this points to is not the need for more isolated solutions, but for systems that are intentionally designed to coordinate. That includes how populations are named, how data is collected, how programs align across aging, HIV, and health care systems, and how accountability is structured across those systems. This is the work ahead. Not just improving access with existing structures, but examining how those structures are designed in the first place. So I will close with this. What we are seeing at the individual level is not random. It is not patterned. and those patterns reflect system design. If systems are fragmented, people will experience gaps. If populations are not visible, they will not be served. The opportunity here is to design systems that are structured to coordinate and intentional about who they include. We exist. We age. We deserve to be named within the systems that are meant to serve us. Thank you.

Yeah, no, that's a wonderful question. Thank you, Senator Laird. I would say a few things. One thing is that we recognize that we need to continually embed lived experience into how we advance the master plan for aging. So hearing more about people's personal experiences and their experiences in the system has been really critical. So we did convene our first Aging and Disability Lived Experience Advisory Board that includes representatives from the LGBTQIA community. And, you know, we feel that what we're learning from there, it really, it's underscoring a lot of the issues that we've heard. And what we do from then is we're going to be building in additional recommendations as we iterate and update the next plan for the master plan for aging. So we could think of specific areas I could highlight, but at this point I can't think of any particular initiative that's standing out that responds to the survey since it was just released.

So a couple of things with that. The focus groups that were held following the survey, we made a big focus on ensuring that we did hear from those underrepresented groups. But I would also say in terms of our program development, it's been really important for us to ensure that in implementation of a different bill, Senate Bill 1249, that is kind of modernizing our structure of the Area Agency on Aging Network, that includes an update to the interstate funding formula that essentially lays out how to distribute the funding from the Older Americans Act across the network. And I will say that we have factored into that people who live in the rural regions to ensure that the rural regions are compensated for the additional resources it often takes to serve people living in those areas. So that's one example of how we're using the findings of people who are harder to serve through our funding formula.

Yes, correct. It was upgrading the Mellow-Granlin Act of 1996.

Well, what I can say about 1249 is that it is updating the way that we, in this example, our interstate funding formula. So that has not been touched since the 80s. So, yes, the idea was that we could update the funding formula to account for underrepresented areas. You know, our population has changed so much since the 80s when that funding formula became in place. So we knew that.

As was I.

And it includes HIV status in that as well.

Well, we actually did include in the front forward part of the revised plan, we did include reference to that. But, you know, it was it was we're balancing a lot of different competing, you know, authorities that review the plan. So we remain committed steadfast in the work we do to uplifting the needs of this population. And in fact, when we speak to the implementation plan, of SB 258. What's really exciting and what's most important is that our local partners are uplifting these populations and it's impacting how they're planning for and funding services at the local level to meet the needs of LGBTQI older adults.

Is this on? Oh, it's on. Okay. So, you know, I think that comment was specifically in light of everything that we know is happening federally, the state government has been slow to respond. And the reason I said that is because if you look at all the work that our friends and stakeholders have talked about, DHCS, CDA, they're not putting in additional resources to make sure that people have the services they need. So if you think about, for example, the survey that CDA did, those results were from 2024. And I understand that there's a need to do more outreach and listen to people with lived experience. But there were a number of community partners who were involved in the creation of that survey. And what we hear from the people that we work with is that people don't know these services exist. So when I was talking about the importance of Medi-Cal-funded home and community-based services and why they're so important for LGBTQ older people, there's a lot more outreach and education that has to happen before people even know that those things, that they're available and they're eligible for them. So what we would want to see is some concrete policies and actions and steps to make sure that people know about these programs and services in addition to – because that's going to ultimately be one way that we can fight back during these cuts.

But not on this specific topic, no.

Well, I'm very systems focused, right? So I'm going to start with the macro level. And I would kind of look at where we are now with the MPA and say, because one of the things that I like the most about the MPA is this idea that we're going to cut across different sectors of the government to provide solutions for individuals like myself. So in this particular time of scarcity in the federal government and what's going to be happening with your budgets and how you're going to find ways to do things, I think since we still are all employed in our jobs at this point, maybe we could actually have some cross-communication about how we're affecting individuals and where those opportunities might be. I go back, my experience goes back to really HIV advocacy. And one of the things that was really impressive to me in the 40 years that we've been fighting HIV is the fact that we've always gone back to community for solutions. And one of the things that we've done is we've actually engaged community more regularly in the kind of decision making. And I remember a few years ago when we were talking about Obamacare. And as an HIV community, we're saying, oh, this is wonderful because Ryan White has such limitations. Nobody's really increasing the funding for Ryan White. But yet we have the eligibility under expanded Medi-Cal to actually transfer a good portion of our population over there. And we're seeing that same kind of a transfer now as people are aging with HIV and are becoming eligible for Medicare. so that there's maybe in the long run, maybe we won't have that same system problem in terms of the health care on the Ryan White side as we've had in the past, but we're still seeing new infections. So, you know, when this population of aging HIV-positive people moves on, it's going to take a while before the next generation is Medicare eligible. So we're always kind of moving the money, I suppose, but we could still be having these conversations, not just within the Department of Health, where all of the Ryan White funding is, but to talk to our friends over in aging or in health and human services to say, what are the opportunities to make sure that our population of people who are aging with HIV are still being served, given all of what's going on in Washington? Thank you.

Sorry, I think I just turned it off. You're good.

There is a lot of work going on at the agency level, but also within our departments through various work groups to ensure that that coordination takes place across the departments, across our community partners, and just more broadly. We do a lot of work to implement the Master Plan on Aging. We're also doing a lot of work on coordination right now on the federal response, which you've heard from every panelist here. So as H.R. 1 continues to be implemented, as more provisions come online and as more federal guidance comes out the door,

Well, we heard how the Department of Aging has a group that they're consulting of stakeholders. Do you have, given the fact that you're trying to coordinate between, you know, managed medical care, the Department of Public Health, and the Office of AIDS, and different segmented groups, do you have sort of a stakeholder group that advises you about how to coordinate between those different departments?

I think that, you know, some consideration might be given to some actual formal stakeholder groups. And I think of the times when I was a cabinet secretary and I might complain to myself about having to go sit a half day and meet with a whole group of people. But then one guy just casually says, you know, Lake Tahoe is heating faster than any lake on the face of the earth. And then the next thing I know, OK, that's something I learned. And it really helps me bring along a lot of people that say climate change isn't happening. And I was able to pull that out of just having all these scientists in one room and have them ruminate about what their work was and what the impacts are. And I found that was really helpful. And so that might be something that you give consideration to because you just don't know in the silos of the department that people are really, as Mr. Kelly said, connecting the dots.

Thank you.

I just wanted to underscore, too, the issue that Jack's raised about connecting the dots, which is so critical, is really one of the key areas that we're focusing on in the Master Plan for Aging. And of course, it's a really significant issue for older adults who identify as LGBTQIA. But I think it's fair to say that older adults and people with disabilities and caregivers are all struggling to access and find the services in a streamlined way. So we just submitted a report to the legislature on some considerations for the development of a no wrong door approach to help people access services in a more streamlined way. So that can be another conversation, but we have many thoughts and considerations for that and have been working with our agency and department colleagues on that as well. And if you think there's something we should be doing to enable that, we need to work with you. We're happy to follow up with you on that.

Yeah, thank you, Mr. Chair. I do have one for Deputy Secretary Kaplan, and it's in the same space, and it's this connecting the dots and sort of lack of information or pathways to services and programs and benefits to which folks are already eligible for. And we have this problem. It's quite endemic in state government more generally. And our solution has been usually to either mount campaigns ourselves or to partner with local or regional nonprofits. And in the last couple of years, your agency and some of the departments have been at the forefront of some of this, Also, then trying to figure out how do we get rid of the dots in the first place? Like, how do we auto-connect them? You know, can we use systems? Recalling that this population, for some folks, they might have taken their first HIV test in the dressing room at a clothing store in Hollywood. They're not as opposed to what would seem perfectly normal today to go to a federally qualified health clinic or go to an LGBTQ center. This is not a population for whom services has been for a large part of their lives has been just out there waiting for you to go ask. And organizational relationships didn't always exist. So the imperative to try to figure out how to find other pathways, and obviously, given technology and the Internet, people have a lot of other ways to get information than they did before. And so, you know, it was a Medi-Cal, auto-determination Medi-Cal eligibility is a huge win for the state and obviously for recipients. and it supplements the work we do through community-based organizations, but it's obviously a systemic level answer to that problem that has been incredibly powerful and profound. Same thing last year we passed legislation to automatically admit every qualified graduate and high school senior to the university. The answer before last year was we need more counselors to help people connect and fill out their applications. We said, well, why do they need to fill out applications? Maybe we could just skip that step. So I'm curious because looking at things like what the Office of Data Innovation is doing in other departments, I don't see a whole lot of A lot in this space is the agency and the departments within your family looking at data, technology, Internet, other means by which we might either connect folks to services and benefits to which they're entitled or to automatically enroll them or to eliminate steps that might have otherwise required their sort of affirmative effort and friction in order to access.

Thank you.

Am I on?

Yes?

Good afternoon Chair Laird members of the committee My name is Paul Aguilar I a 62 fourth native San Franciscan and I sit before you today as a representative of a historic cohort the first generation to age with HIV. In 1988, when I received my AIDS diagnosis at the age of 25, the medical consensus was I wouldn't live to see 30. Because I survived, I'm a living example of a public health triumph. I'm part of the 75% of the San Franciscans living with HIV, but I'm being crushed by a survivorship penalty. I'm here to speak about the ambitious goals of the California Master Plan on Aging. Aging with dignity, health reimagined, housing for all stages, these are noble goals, but they're currently being sabotaged by an infrastructure that has yet to fully see the long-term HIV survivor. The Master Plan for Aging aims to help us afford aging, yet our community is navigating a total vacuum of legal services, benefits navigation, and client advocacy. This is a direct consequence of the Department of Aging's failure to prioritize HIV long-term survivors, despite the clear mandate established by SB 258, the HIV and Aging Act. The legislation introduced by Chair Laird and signed into law by Governor Newsom in 2021 was intended to ensure our unique needs were integrated into the stage aging framework. Instead, we remain an afterthought, left to navigate complex federal and state bureaucracies without professional advocacy necessary to survive them. Because of this lack of state-level protection, I was blindsided a year ago by the federal government with the $201,000 clawback bill for a minor income discrepancy that happened 13 years ago. Over these past 12 months, while my appeal is still pending, the Social Security Administration stopped my disability payments, terminated my Medicare, threatened to garnish my modest part-time income, and tanked my credit score from 780 to 440. As far as the Social Security Administration is concerned, my survival is a debt I can never repay. And this is not just a federal issue. It's a state-level failure of protection. Without state-funded legal and navigation services specifically for HIV survivors, the Master Plan's goal of economic security is a fantasy. We're being punished for the mistake of staying alive. The master plan emphasizes aging in place, but that requires having a place to begin with. The only reason I am not currently living on the streets of San Francisco right now is because of Marty's Place Affordable Housing Corporation. It's the nation's only self-governing, low-income, independent living housing cooperative for people with HIV and AIDS. But a single cooperative cannot be California's entire safety net. California has the opportunity to address the crisis today. The End the Epidemics Coalition is requesting a $50 million in ADAP rebate funds specifically for housing services. I urge support for this request. For the long-term survivor, the benefits cliff is so deep that traditional affordable housing is not enough. We need specialized, resident-led models that understand our medical and financial history. because for those of us living with HIV, housing is health care. Finally, our current state policies actively penalize those who attempt to adhere to meaningful involvement of people living with HIV. I work an average of 16 hours a week at the San Francisco AIDS Foundation in order to stay in touch and give back to my community Yet California own Working Disabled Program which supposedly encourages part work requires that a person still meet a Social Security Administration definition of disability based on 1995 clinical guidelines, back when HIV was a death sentence. Because of those outdated standards, I was notified on April 2nd that I am now losing not only my Medi-Cal coverage, but my food stamps as well. The system is telling me to keep my health care, I must remain in total poverty. And to keep my health, I must stay disabled by 30-year-old standards. That is not health reimagined. That is health extorted. We don't need noble declarations. We need legislative accountability. We need to hold the Department of Aging accountable to the mandates of SB 258. We need to fund the $50 million in ADAP rebate funds for HIV-specific housing services. And we need to establish state-level legal and benefits navigation services to protect survivors from the predatory federal clawbacks and the benefits cliff that I am now precariously close to falling over. Right now, many of my peers feel like we're back 45 years ago when it all started. Just as the San Francisco model of care revolutionized the relationship between provider and patient globally, California now has the opportunity to redefine what it means to age with HIV. We can replace a system that is antiquated and anachronistic with one that actually works. And I just want to leave you with one thought. When I was first interviewed for the position I hold in the San Francisco AIDS Foundation, my supervisor asked me a question that no one ever thought to ask a 25-year-old with a death sentence. What is the world you wish to age into, and what are you doing right now to create it? So I ask you, members of the committee, what are you doing to create it? Thank you for your time.

of 2021 by Senator Laird, which expanded the definition of greatest social need to include HIV status. By way of context, every four years, the Department of Aging requires the state's 33 area agencies on aging to develop an area plan that assesses local needs and specifies how that service area intends to disperse Older American Act resources to meet local needs. The area agencies on aging are required to prioritize resources according to factors outlined in the department's definition of greatest social and economic need. And as articulated in the Welfare and Institutions Code, the greatest social need refers to the need caused by non-economic factors that restrict an individual's ability to perform normal daily tasks or that threaten an individual's capacity to live independently. So SB 258 updated the definition for social factors to include HIV status adding to existing factors of physical or mental disability language barriers cultural or social isolation caused by racial and ethnic status sexual orientation gender identity or gender expression It's important to note that under federal law, the Department of Aging is unable to dictate how the area agencies on aging distribute their funds or how they determine the greatest social and economic needs in their local areas. But the Department is required to ensure that the Area Agencies on Aging understand the definition of greatest social and economic need and how it can be applied in the Area Plan. So upon implementation of Senate Bill 258, the Department of Aging issued communications to the 33 Area Agencies on Aging to familiarize them with this new requirement for their area plans. Prior to the most recent area planning process, the Department of Aging research staff developed an index of greatest social and economic need factors, including HIV data from the Department of Public Health. The index was presented to the area agencies on aging in November of 2023 and in May of 2024. And we are also under the leadership of our research team updating our data dashboard for aging to include HIV data on a county-by-county basis, among other data. And we have heard from our Area Agencies on Aging partners that they utilize this data from the Data Dashboard for Aging to help inform their area plans. In the latest round of area plans that were submitted at the end of May 2024, 20 of the 33 area agencies on aging identified HIV as a target population of need. And among those 20, 16 outlined specific strategies to address the needs individuals with aging with HIV have and making them a priority population. As an example, one of the area agencies on aging noted in the area plan that, quote-unquote, consumers who identify as Black, Indigenous, and people of color and or LGBTQIA identified a need to feel included and comfortable when accessing services. So the area plan in this county emphasized the importance of being focused and intentional in providing inclusive services to the LGBTQIA population with attention to the unique needs of specific subgroups, including individuals living with HIV. Finally, when outlining strategies for serving priority populations, the area plan included dedicated services tailored to address the unique needs of priority populations, which includes, for example, the new LGBTQIA Mental Health Connections Program. And in this region, that program provides short-term counseling and therapy services to LGBTQIA individuals and HIV long-term survivors aged 50 and older. In addition, that area plan included resources to continue piloting an LGBTQIA mental health connections program, as I noted, that provides counseling and therapy services to HIV long-term survivors. So that's just one example of one of the area plans and I am happy I have all the examples with me But I'm happy to follow up with staff and provide links to all of the area plans so you can get more information on that And I would just like to say that in conclusion the Department of Aging is pleased with the progress that our area Agency on Aging partners have made in prioritizing services for the population of older adults living with HIV. And that in no means is a way of saying that the issues expressed by the panelists are not real. They are real. And there's always more that can be done, and we can always do better and work more effectively to help educate our local partners. So we appreciate the partnership on all of that. So thank you for your time, and I'm happy to answer any questions you may have.

Thank you.

My name is Jessica Heskin, and I am the Assistant Office Chief for the Office of AIDS at the California Department of Public Health. I am happy to join you in this important discussion on health care and support needs of older LGBTQ plus Californians. I will be sharing a lot of information about our programs, and I would like to begin by sharing information about Project Cornerstone, which is funded through the AIDS Drug Assistance Program, ADAP. Project Cornerstone was established in California Health and Safety Code 12-12-95 in the fiscal year 2022, supporting the development of four public health demonstration projects. Selected applicants were awarded through a competitive award process to provide innovative, evidence-based approaches to improve the health and well-being of people living with HIV or at risk of HIV, 50 years of age and older, PLWH 50+. Projects address the increasing complex needs of the expanding population through the integration of clinical and non-clinical care required as people living with HIV age, as well as coordination of stigma-free, trauma-informed, culturally and linguistically competent services for PLWH 50+. The project period was July 1, 2023 through June 30, 2025. Data analyses and a report of the projects are in progress and will be available before the end of the year. The Ending the Epidemics Integrated Statewide Strategic Plan addresses HIV, HCV, and STIs in California, marking progress towards more equitably addressing the health needs of all Californians. The plan is laid out into six social determinants of health, each comprised of five strategies to guide California towards ending HIV, HCV, and STIs. Proposed strategic plan actions pertaining to people living with HIV and aging include earlier and more frequent comprehensive health screenings, education on navigating benefits and services, particularly those transitioning to Medicare, and ensuring that mainstream aging care providers understand and appropriately respond to the unique needs of older adults living with HIV. I will move to Ryan White in HOPWA. CDPHOA administers the Ryan White Part B program throughout the state via two programs, the HIV Care Program or HCP and the aforementioned ADAP program. While not age specific, HCP funds counties to provide medical care, case management, mental health, food, transportation, housing, and other services designed to keep low-income Californians with HIV virally suppressed In 2025 HCP served 6 clients that were 50 and over ADAP insures medication access for uninsured or underinsured Californians living with HIV ADAP has expanded to an open formulary aligned more closely with Medi-Cal's broad medication coverage, reducing treatment interruptions, especially for clients whose insurance changes between ADAP and Medi-Cal. ADAP now covers nearly all FDA-approved medications and an open formulary is especially critical for aging clients who often manage complex comorbidities that require integrated and responsive medication support. ADAP served 14,756 clients in 2025. ADAP clients may also qualify for insurance premium assistance through various programs that are funded through ADAP, including the Medicare Premium Payment Program. And in 2025, MPPP served 8,354 clients that were 50 and over. Moving to the Housing Opportunity for Persons with AIDS or HOPWA program, which is not a Ryan White program, CDPHOA administers the HOPWA program for 40 counties in California that are not directly HOPWA funded by HUD. HOPWA does not have programs specific to aging populations, but HOPWA does provide short-term rental assistance, food, transportation, hotel-motel assistance, case management, and move-in assistance. In 2025, HOPWA served 610 clients who were 50 and older. The Medi-Cal Waiver Program provides comprehensive case management and direct care services to persons living with HIV as an alternative to nursing facility care and hospitalization. Case management is a participant-centered team approach consisting of a registered nurse and social worker case manager who work with the participant, the primary care providers, family, and caregivers. There are 15 Medi-Cal waiver providers throughout California serving 1,250 participants in 2025. Pre-exposure prophylaxis, PrEP, assistance program, PrEP-App, covers the cost of PrEP, PEP, and other medications, lab tests, and doctor visits for people at higher risk for HIV. PrEP-App served 520 clients that were 50 and older last year. Coordination with HIV and aging services. While CDPHOA does not directly coordinate services, local level, Ryan White and HOPWA case managers are expected to conduct whole person assessments of clients to address gaps in services. These case managers ensure long-term survivors receive the support they need from various governmental and community-based organizations in their area. In conclusion, we appreciate your time and ongoing partnership on these issues, and I'm happy to take questions at the appropriate time.

Thank you, committee chair.

I've not always been a senior medical case manager for the Ryan White program. I started my journey in 1989 in San Francisco when I got my first diagnosis. I had moved there in 76 with four of my friends We thought we were going to find a new life with our new community and it was just amazing And in about 78 we started hearing little rumbles about something that showed up I remember being on the corner at Castro and 18th, and Star Pharmacy was there at the time, and there was a picture of a guy up in the window with purple spots, which we know is Carpozzi's sarcoma. And everybody thought, well, what are they doing to us now? You know, they're attacking us from the churches and everything. and we didn't believe something was going on. We thought the government was up to something, you know. But as time went on, we had a disease that showed up that was just taking people out left and right. We used to go down in the Castro to get the bear reporter page after page of who died. And we all wondered if we had all caught something somehow. Nobody knew how it was transmitting. It was really strange. so when I tested positive I had already lost so many friends and they were just going so fast so I had come back to Sacramento I didn't trust the medications that were out at the time AZT people were really getting sick off of it and I thought well that's not the answer so I I didn't feel sick so I just continued life and then in 2003 I was not adherent to medication I didn't believe in it. I was diagnosed with terminal colorectal cancer and full-blown AIDS. UC Davis didn't think I'd survive, but I did. I pulled through. Then I discovered CARES, the Center for AIDS Research and Educational Services. I started going there, and as I got well, I started doing some supportive classes. And one day they asked me if I wanted to be an HIV test counselor. I said, okay, sure, I'll try it. Come to find out, I really loved it. And I got good at counseling. And in 2010, the director asked me, hey, we've got a case management job for Brian White open. Do you want to do it? I go, I don't know anything about case management. They go, oh, yes, you do. You just don't know it. And I've been doing it now. This June will be 20 years. and I leaned on Ryan White, HOPWA, and ADAP program for many, many years, and today I administer those programs. Half my clients are over the age of 55, and I've heard a lot of things that ring true for the patients I work with because a lot of them isolate. They're afraid of the stigma. They don't want anybody to know they're HIV positive. I was lucky enough in 2006 to become a Shanti Life Facilitator from the Shanti program in San Francisco. I directed that program for Northern California. I've been up on the Hill in Washington two different times speaking for Ryan White Funds. It's been an amazing journey today. I teach other case managers to do what I do. I've learned the program inside and out. HOPWA is my specialty. I know that program. And ADAP. I love ADAP. I love administering the programs for the elderly, the MPP program, OAHIP program, EBHIP program, which is employee-based premium assistance. Anytime somebody is before me, I go through their whole budget to see what they're eligible for besides the ADAP program because it's a wonderful program. And now as of January 15th they have the full formulary FDA approved medications so they cover everything And I was working with one of the girls from the pool administration the other day because they moved they've taken on the GOP-1 drugs for diabetes and weight loss, and there is a criteria to use it. Because if your primary insurance denies you, like Medi-Cal now denies it, And I'm working with somebody there to see if we can get a workaround on that from Medi-Cal patients to get their GOP-1 drug. And it's hard on patients when they lose medications and no way to get it. For undocumented clients, that's another step for them when they lose everything from when they were cut off Medi-Cal. We can get their meds for them. That's a big deal for people to get their medication covered because the prices of them are so expensive. You know, they'll come to me all the time. How am I going to pay for this? Or they come to me with a bill, you know, and that they can't pay, and they're so scared that they're going to go to collection. I work with clients that go to One Community Health with FQHC, and they'll come to me with their bills, and I'm going, and FQHC cannot turn you away from services, and they can't turn your bills into collection. You can pay $1 a month if you can, and they have to accept that. And so when they find that out, because they don't tell people that over there anymore. I don't know what that's about. But I worked at CARES for 15 years, so I know how their system works. And when it became a federal qualified health center, they used the EPIC system, their computer system. And I got on there, and it was like a video game for me. I just did it like it was no tomorrow. but I give back to my community because the community gave to me so much in my early days CARES was the center that brought me back to life and I turned 71 this year I've been living this for a long time and I'm going to continue my journey with it and I'm glad to be here and I'm glad to help out any way I can

Thank you.

You're very welcome.

Of course, at this time, it's going to be a few years before the money is paid back, obviously. So I can't comment on specifics. I think there is opportunity. We always listen to stakeholders.

I imagine that we could consider it if we got a proposal for it, sure.

I wasn't expecting that.

Well, as I said also in my testimony, there is a request from the Anti-Epidemics Coalition for a $50 million towards HIV-specific housing. Because that is – we have clients, 70% to 90% of their income is for housing, and that is – that's crazy. so that could be one of the things also I'm wondering with ADAP we have some clients with some of the new rebates that are no longer available to them through the Affordable Care Act one client whose share of cost was $2,500 a month is now $6,500 a month, it's more than he gets from his Social Security. That might be another thing that ADAP might be able to do, some offsets. I mean, there's a lot, but that's one start.

Because people, I've lost a lot of patients that were on the exchange and they just dropped their insurance. There's no way for them to cover it.

Even though that was unsettling. Let me just ask one last question of the Department of Aging, which is we've been talking about Senate Bill 258.

So I'm going to follow up and provide a link to all of the different area plans.

There are 13 of the 33 that you said, I don't know, weren't in the same status where 20 had it in their plans and were identifying it. If it turns out over time that some in those 13 just are ignoring the law or ignoring the priority, what is the recourse?

And if we were just talking about ADAP, could ADAP monies be used to, I don't know what the polite phrase is, to jam them to figure out how they implement the law and prioritize this?

And we really want you to come back with who might not be implementing that bill, because whatever the strategies are for that to happen, we're going to want to do it, because that wasn't done in some isolation. and generally, I hate to say this, but some of the places that are the last to implement are the ones that need it the most. And so we might really want to work with you.

There's a point at which volunteerism isn't enough.

Let me go to my colleagues and see if people have questions. Mr. Weiner.

Thank you for your comments.

Yeah, thank you. Thanks, Mr. Chair, and thanks to the whole panel. So I'm, this is not my normal research style, but I was just trying to do a quick check on a fact. And so I typed in California Department of Aging HIV into Google. And I'm on page seven of all the results, and there is nothing. And so when we say we're working really hard to educate the area agencies on aging, it should be, if you're looking for it, it should be findable. And so I'm just noting that as Deputy Director Steenhausen that I think even the department may have some work to do. Maybe it's just search terms, but if I can't find it, I'm looking for it. It's got to be hard for these agencies that aren't looking for it, aren't hoping to be not noticed in their failure to comply, that they will also be found. But I also wanted to query you, though, because during your testimony, you mentioned the key findings about why folks weren't accessing services were, I think you said something about the language that's used isn't inclusive. Was it in the early part of your testimony? Yeah, I'm going to look that up, but in particular you're talking about. Let's see the trust barriers. Let's see. Yeah, I have to, I'm trying to remember where that was said, but that they, that the issues of not wanting to explain, have to continue discussing identity? Was that what you're referring to? Yeah, it might be. What struck me in the moment of hearing it, and partly because I'm in the middle of a couple of these generations is that as I was listening to it it sounded and this would be completely crass it sounded like a sort of millennial Gen Z designed program for older adults These are populations that for many folks during their entire life they have rarely uttered the words authenticity, inclusion, intersectionality, what have you, but they have uttered the words, where's my benefits? Right, right, right. You know what I mean? These are generations that are accustomed to much more direct, formal language and not generally saying I don't feel affirmed when what I really need is my housing voucher or what have you. And so I'm just, it struck me as we're thinking about the design of these efforts to assure that we're really, we're designing for the user and not from our own lens, but to really understand, meet folks where they're at, both in language and approach. It was reinforced a bit by the 2024 survey as well that, you know, kind of tops of the list were, you know, I don't think are qualified. Insurance doesn't pay. You have to go pretty far down the list before you're like, I'm not feeling affirmed.

Okay. I'll follow up. Yeah, no, it's a great point. I was about to say it triggered me, but then I realized that's exactly the opposite of what I was just saying. But it's just a reminder to understand. I think particularly, you know, this is true across, you know, even not for the LGBTQ population, just looking at generational differences. But then when you layer on top of it, surviving HIV specifically, but then also surviving a world in which you're completely ostracized, that you're kind of your level of like, I just need to get my needs met specifically as opposed to I'm expecting the world to be more understanding, embracing and affirming. They're both important, but you have survived a world that wasn't really looking to support you. Right. And right now at this stage, I have my bills to pay. I have my services that I need. So anyway, thank you for prompting the question. But I do think as we continue to pay attention to these issues, the sort of user-centered design around these efforts, since so much of the problem, as we've heard, is both the services but also the connection and the access of services and benefits that already exist and are funded as well. Thanks.

Thank you. And once again, I feel like I would really like to keep this discussion going, and I am sorry that we're running late and we have to get to our last panel. But in particular, I think this panel is very interesting in that we had two people from departments and we had two people with lived experience. and our challenge as elected officials is to mix that up and to make sure that the needs that we just heard in the lived experience are reflected in what you're doing in the departments and I know in the first panel when it was said the dots weren't being connected in some ways there are some themes that are passing through the different panels but even though I know you might be not able to say something before the May revise we will be looking at things when the budget comes in in trying to make sure those links are are made but I have a feeling that this this hearing has been much more rich than I thought it was going to be and we're going to have to have a list of things that we want more information and follow up on to see how we're going to link it so I just thank you all for being here today you really helped with this discussion. We're going to move to our third and final panel, which is health care and supports for TGI seniors. And we have a representative of the Department of Social Services, Claire Ramsey, the Chief Deputy Director. And from the Department of Public Health, We have Heather Chamizo, the Chief of Field Operations for the Northern Division of Center for Healthcare Quality. And from the Trans-Latin Coalition, we have Bambi Salcedo, who's President and CEO. So let me welcome all three of you here, and we'll go in that order, and we'll start with the representative of the Department of Social Services. Welcome.

Thank you, Chairperson Laird and the select committee members. As you stated, my name is Heather Chimizo, and I am the Chief of Field Operations North Division within the Center for Health Care Quality at the Department of Public Health. The Center for Health Care Quality, known as CHCQ, is responsible for regulatory oversight of licensed health care facilities and health care professionals to ensure safe, effective, and quality health care. CHCQ fulfills this role by conducting periodic inspections or surveys and complaint investigations of health care facilities to oversee compliance with federal and state laws and regulations. CHCQ licenses and certifies over 14,000 health care facilities and agencies in California in 30 different licensure and certification categories. In addition, CHCQ oversees the certification of nurse assistants, home health aides, hemodialysis technicians, and the licensing of nursing home administrators. As my counterpart in DSS was talking about the implementation of Senate Bill 219, which is also known as the Lesbian, Gay, Bisexual, and Transgender Long-Term Care Facility Residence Bill of Rights, was passed in 2017, as you were all aware. And that requires all health care facilities, including DSS and CDPH facilities, to implement the policies that my counterpart did lay out very eloquently, so I won't go through all of those. But we do focus on making sure that there's preferred pronouns, use of restrooms and rooms as needed or as appropriate, and gender identity and providing the proper medical care and non-medical care for our residents. On November 14, 2017, CDPH issued our all facilities letter 17-24, and that is comparative to the PIN that DSS issues. And this notified all long-term care facilities of the passage of SB 219 and the requirements and the fact that they would be effective January 1, 2018. And we also added all of those requirements of the bill to our survey tool. And so our nurse surveyors, when we go in and do these inspections for relicensure, we have added that information to our survey. So in preparation for this hearing, I did request some data about the complaints and the deficiencies cited for SB 219 under those code sections. So in the last five years, CDPH has received zero complaints from residents or the public and only noted two deficiencies during routine licensure surveys. So while we were on site, we did have two deficiencies since the implementation of 2018. Our staff that respond to questions from facilities and public have no records of questions related to this legislation. So our data does indicate that our CCA. CDPH licensed long-term care facilities are overwhelmingly complying with SB 219's requirements. Moving on to talking about our safe and affirming long-term care facilities. CDPH doesn't specifically track facilities as safe and affirming, as we expect and have the requirements that all our licensed and certified facilities will meet the requirements of statute and regulation. which includes resident rights for all of our residents. There also are additional regulations that require specific skilled nursing facility staff to receive training designated to eliminate and prevent discrimination based on actual or perceived sexual orientation, gender identity, and gender expression, and they must receive that at least once every two years, and that began in August 2018. Thank you for your time. Appreciate it. And if there's any additional questions, please let us know.

Thank you so much, Chair Lair and members of the committee. My name is Bambi Salcedo. I am a 56-year-old Trans Latina, and I have the esteemed privilege of serving as the CEO and the president of the Trans Latina Coalition, which is an organization dedicated to advocating for and serving trans, gender-expansive, and intersex communities. I do want to say also that I am a long-term survivor of HIV and an aging transgender woman. I stand before you not only as someone with live experience, but also as a service provider, program developer, and a researcher who has spent years working directly with trans, gender-expansion, and intersex communities across California. I am fortunate to be living a healthy life today. But that survival is not accidental. It is the result of access to care, education, community support, and medical advancements in HIV treatment and prevention. Many of us did not have these resources in earlier decades, and many aging transgender people still do not have equitable access today due to ongoing systemic barriers that follow us into older adulthood. We must be clear that transgender women of color continue to experience some of the highest rates of HIV infection in the United States. This is not about individual behavior. It is about structural inequalities, including poverty, housing instability, discrimination in health care, and the persistent lack of cultural competence services. services. While we now have life-saving tools such as PrEP and effective HIV treatment that make long-term survival possible, access remains deeply an event for our community. In our work we consistently see that whether someone is able to remain in care depends on language access, particularly for monolingual Spanish-speaking individuals, immigration status, and fear of systems where someone is connected to affirming, competent providers, or navigating a loan, these structural barriers do not disappear with age They intensify especially as people transition into systems of elder care and long care facilities Through our community research and direct service work we have learned that gaps in care are not incidental. They are predictable and systemic. We see Very often the delay of HIV diagnosis due to lack of performing providers, also interrupted treatment due to housing instability, avoidance of care due to fear of discrimination or prior negative experiences, deep isolation among aging transgender women, specifically those disconnected from mainstream aging systems. These realities are particularly urgent as more transgender and HIV-positive, individual-centered lung care system settings that were not necessarily designed with our communities in mind. This is where SB 219 becomes critically important, as it directly addresses the kinds of discrimination that too often determines whether someone is treated with dignity or is pushed out of care. By clarifying that long-term care facilities cannot denied admissions transfer discharge or refuse to recognize the person's name, pronouns, gender identity, or HIV status, and by requiring visible posting of these protections, these bills transcend both accountability and awareness in systems where harm has too often gone unaddressed. And there's many stories of trans women who have experienced some of those issues. In response to many of these gaps, we have developed programs that not only provide services, but build leadership, power, and protection through community. One of these efforts at our organization is a cohort that we have at our organization that is called the Diamonds. The Diamonds are aging transgender women, many living with HIV, many who survived the most devastating years of the epidemic and who also were neglected when they started their transition, such as myself back in the 80s and even before that. Some of these diamonds engage now at organization and advocacy and leadership development, health education and system navigation, peer support and community care, policy engagement, and storytelling. One of the projects of our storytelling was the Drill and Cut, Diamonds of Resilience, which is a full-length documentary on aging trans women, their hopes, issues, and dreams. This could be available or is available on our YouTube channel free of charge, so just an educational component. This model is grounded in our simple truth. Aging transgender women are not passive recipients of care. They are experts, caregivers, historians, and policy voices. But we also recognize a limitation. Programs like this are not yet systemic. They remain fragile, underfunded, and dependent on short-term resources. Without sustained public investment, these funds cannot scale to meet the growing needs of aging transgender communities, entering long-term systems. Aging trans people, especially those who survived the early HIV epidemic, have lived through decades of exclusion, violence, and systemic neglect. Many enter adulthood during the time when care systems explicitly deny them dignity. Today as they age they are once again entering systems particularly long care where their risk of discrimination can determine whether they are seen respected or erased We have a responsibility to ensure that DGI elder adults are not once again excluded from the systems meant to care for them in their most vulnerable years What this means is that we need to ensure enforcement of protections like those in Senate Bill 219, investing in culturally competent long-term care systems, investing in mandated training, expanding access to affirming health care across their lifespan, and supporting peer-led models of care and advocacy. My call to action today is that SB 219 is obviously an important step forward, including that LGBT and HIV-positive alternative tools are not quietly pushed out of care systems through discrimination, neglect, or invisibility, particularly as they enter long-term care settings where vulnerability is often highest and oversize and too often weakest. But passing protection is not enough on its own. The state must also ensure these rights are understood, enforced, and lived in practice by the people who depend on them every day. That means building systems where transgender, gender-expansor, and sex older adults are not only protected on paper, but are actively seen, respected, and affirmed in their environments. Across California, TGI and older individuals, many of whom survived the most devastating years of the HIV epidemic and decades of systemic exclusion, remain essential members of our communities. They are caregivers, culture knowledge holders, advocates, and leaders who continue to shape the present while carrying hard-earned history that benefit us all. We must give them their flowers now through action, protection, and sustained investment in their dignity. We want to make a new history and not repeat the history of the exclusion of the most vulnerable population in our society. We have an opportunity to redo the damage that the harm that was done to trans women in decades past. Sylvia Rivera is not considered the mother of the LGBTQ movement, yet she died homeless without any type of support. Trans women are neglected then and continue to be neglected now. In the name of Sylvia Rivera, I ask that you now acknowledge, uplift, and value all TGI people, but prioritize trans women of color. I don't want to have my life end the way the life of Sylvia Rivera ended. Now is the time to invest in support on all transgender, expensive and sex people who were neglected for many years. I believe that we can create the change that needs to happen, but it will require for all of us to see that change. My hope is that I can get to see that change and that at least my community is valued and dignified the way we should. Thank you so much for the opportunity to address you. Thank you so much

Great. Thank you, Mr. Chair. First of all, I just want to say to Ms. Salcedo, thank you for all of your amazing work. We actually partnered for years on SB 132 to ensure that trans people who are incarcerated are treated like actual human beings. and over time there's been just this massive misinformation campaign about SB 132 and about trans people who are incarcerated in general. And the other day I was walking through the Capitol and a trans woman approached me and talked to me about how she was incarcerated in a men's facility. And after SB 132, she had been stabbed and raped. And after SB 132 was passed, they started to treat her better and actually focus on her safety and safety of others. So thank you for your work, and thank you for working with us for people who are just regularly dehumanized in society. um and on um sp219 um so it's it's your i'll be honest i've not uh and this is a good thing i've i've not heard a lot like i've normally i would hear reports of problems and i'm sure they're always going to be problems uh nothing's going to be uh perfect um but i have a sense that uh facilities are taking it seriously? And is it your sense that that is broad? Like, are you getting a lot of complaints in there? And that's about 219.

Great. Thank you very much. And I want to just acknowledge SB219, I can't believe it was almost 10 years ago, one of the first bills I introduced as a new senator. It really grew out of amazing work in San Francisco, where we worked with a whole bunch of people like Marcy Edelman and Tom Nolan and Daniel Redman, and at the time a very young guy who was very focused on supporting LGBTQ seniors and did a whole task force at the Board of Supervisors, came up with policy recommendations, and this was one of them, and we passed it at the Board of Supervisors, and then we took that to the legislature. And so I just want to acknowledge that really grassroots organizing, that was the genesis of a lot of this work. Thank you. let me sort of follow up in a way because one of the things that was highlighted is that there's training to health care providers. How do you ensure that the training actually translates into patient safety?

But I think there's a couple things. One is on the administrator trainings, there's actually like a test to make sure that they have like learned the material and absorbed the material and are certified to be an administrator. For the staff that are receiving the training, while we don't oversee it directly as the department, we do obviously take complaints and we do follow up where it seems like staff has not been basically putting it into action. So if we've received complaints related to somebody's mistreatment or discrimination, one of the things we can follow up in our plan of correction, which we do with facilities when they do have substantiated complaints, could potentially be, for example, having a staff member take training again or having them engage in additional work to make sure that they are respecting residents' rights, especially around LGBTQ issues. So it's not that we're directly doing the training, but that I think we do have mechanisms in place to both hear about problems and then to follow up and require plans of compliance.

So a few different, all good questions. I'll sort of take them as they come. So first, if somebody does lodge a complaint with our centralized complaint bureau, we have 10 days to go out and do an initial complaint investigation. That doesn't necessarily mean the complaint is closed or the finding is determined in that first visit, but we have to basically follow up. And we have a very good record. Is that sort of just a basic determination of whether there's validity to the complaint and it could keep going after that? It could potentially, but, you know, our complaint investigations can be pretty quick and straightforward, or they can be very large and complex. So it sort of depends on what the allegation is, and a complaint can contain multiple allegations. So to your question about how quick or long it takes, it really is dependent on how many allegations in the particular complaint, how serious the allegations, how much additional evidence is needed to be gathered. We can interview witnesses. We can talk to staff, administrators, residents, roommates. We can follow up if there's paperwork or other information or reports that we need to follow up on. So our investigations can kind of expand to fit the need. So once we've done that initial outreach, we can, again, depending on the size of the complaint, determine whether we can substantiate or unsubstantiate at that first visit or whether additional work needs to be done to follow up If we do determine that let say a resident was discriminated against or was treated poorly or inappropriately by a staff member we can call a noncompliance conference with the licensee. We can work with them at that conference, which is supposed to be collaborative, to do a plan of correction that could include training and other, you know, actions toward the staff or more broadly toward the overall, you know, basically how they're handling the overall management of the facility depending on the scale of the problem. And then we do do checkups and follow-ups to those plans of compliance to make sure that they were actually completed and people took the actions that they were required to take. We can also sometimes, if a facility has had sort of more ongoing problems, do sort of drop in case management visits as needed if we think so. And we also have obviously unannounced yearly visits that are required. So there's sort of a lot of different touch points. And then if things are particularly egregious, there are civil penalties, enhanced civil penalties. We can exclude staff members. We can revoke licenses. So there's a pretty wide array.

I think we do have adequate tools. I think your point about whether staff members are realizing the training and making it, you know, actionable in their lives, I think is always a challenge, again, as a licensor or regulator, because we're a step removed from the direct management and oversight. But we do work hard to make sure that all our residents are being treated appropriately.

I have some information here. Let me see if it answers your specific question. If not, I can take it back and bring you more. We do look at our complaints every year, and we do try to poll what the most often cited complaints are. What I need to check with the team is if personal rights is one of the higher ranked ones, whether we can drill down to what the particular personal rights violation is. And let me see. Hold on.

All those people could file a complaint.

So we can take a complaint from anyone, including always a resident. But, yes, it could be somebody who witnessed it. It could be somebody, a family member of the resident. And we do have to investigate.

I feel like SB 219, it seems like CDPH is finding similarly that that was pretty strong, like, mechanism to create the environment that I think we're hoping that all residents will live in where they feel safe and welcomed and that they can be themselves. Let me take back and see if we're seeing anything where we think there's additional strengthening that could happen there. and I looking and I not seeing the statistics that I was hoping to find to answer your question so I happy to take that back and get more information on our complaints You would be interested in that Sure Let me ask the Department of Public Health if you want to comment on that

and you're not talking about your own deficiencies. That's the way it sounded. Sorry.

Thank you. And, Ms. Alcedo, it looked a moment ago like you had something you wanted to say.

Okay, thank you. Senator Cabaldon, do you have any questions?

And we want to, even though we're way over time. Let me just take an informal survey. Is there anybody here that wishes to give public testimony that hasn't? I see three hands and maybe somebody running from the hallway. So let's do that. And let me thank the panel so that they... And if you move to the microphone, we'll give you a minute or two, each of you, to express anything that you would like to express about the topics that have come up in today's hearing. And as usual, it's three hands, four people, now five people. So hopefully nobody else is running in, but welcome to the committee.

Thank you very much. Welcome.

Thank you very much. Appreciate your comments. Welcome.

Thank you very much. Appreciate your comments. Welcome.

Thank you very much. Welcome.

Thank you, Senator. Thank you, Chairman and Senator.

Thank you very much. I appreciate your comments. And thank everybody that testified and attended. And I want to thank my colleagues, Senator Cobaldon Padilla and Wiener for attending. And I would say also that this is going to be an ongoing conversation. So if you have further comments or further things you want to bring to the select committee, you can write the select committee, care of my capital office, and we will take into account those comments and incorporate them into our discussion. With that, thank you for bearing with us, because I know we ran way past the time that we promised that we would adjourn. I'm sure some sergeants are just really happy this moment is finally arriving. And so we will continue this conversation. I thank everybody for their participation. It was a successful hearing, and the committee stands adjourned. Thank you.