BILL ANALYSIS Ó SENATE COMMITTEE ON HEALTH Senator Ed Hernandez, O.D., Chair BILL NO: AB 50 --------------------------------------------------------------- |AUTHOR: |Mullin | |---------------+-----------------------------------------------| |VERSION: |May 21, 2015 | --------------------------------------------------------------- --------------------------------------------------------------- |HEARING DATE: |July 8, 2015 | | | --------------------------------------------------------------- --------------------------------------------------------------- |CONSULTANT: |Scott Bain | --------------------------------------------------------------- SUBJECT : Medi-Cal: evidence-based home visiting programs. SUMMARY :1) Requires the Department of Health Care Services to develop a plan on or before January 1, 2017, to ensure that evidence-based home visiting programs, as defined, are offered and provided to Medi-Cal eligible pregnant and parenting women. Existing law: 1)Establishes the Medi-Cal program, which is administered by the Department of Health Care Services (DHCS), under which qualified low-income individuals receive health care services. Children up to age 19 are eligible for Medi-Cal in families with incomes up to 266% of the federal poverty level (FPL) (266% of the FPL is at or below $52,641 annually for a family of 3 in 2015) and pregnant women are eligible with family incomes up to 322% of the FPL 2)Establishes the Nurse-Family Partnership (NFP) program, which is administered by the Department of Public Health (DPH), to provide grants for voluntary nurse home visiting programs for expectant first-time mothers, their children, and their families. Requires a county to satisfy specified requirements in order to be eligible to receive a grant. The provisions of the NPF program are subject to the normal Budget Act process and are operative to the extent funds are appropriated. This bill: 1)Requires DHCS to develop a plan on or before January 1, 2017, to ensure that evidence-based home visiting programs are offered and provided to Medi-Cal eligible pregnant and parenting women. Requires DHCS to develop the plan in consultation with stakeholders, including, but not limited to, representatives from Medi-Cal managed care plans, public and AB 50 (Mullin) Page 2 of ? private hospitals, evidence-based home visiting programs, and local governments, from diverse geographical regions of the state. 2)Requires DHCS to consider all of the following in developing the plan: a) Establishing Medi-Cal coverage for evidence-based home visiting program services; b) Incentives for Medi-Cal providers to offer evidence-based home visiting program services; c) Other mechanisms to fund evidence-based home visiting program services for Medi-Cal eligible pregnant and parenting women; and, d) Identifying among evidence-based home visiting programs those with established evidence to improve health outcomes, the experience of care, and cost savings to the health care system. 1)Requires DHCS, in developing the plan, to prioritize the identification of funding sources, other than General Fund moneys, to fund evidence-based home visiting program services, including local, federal, or private funds, or any other funds made available for these program services. 2)Requires DHCS, on or before January 1, 2022, and every five years thereafter, to report to the Legislature on implementation progress and the effectiveness of evidence-based home visiting services in improving maternal and child health outcomes, the experience of care, and cost savings to the Medi-Cal program and the state. 3)Defines an "evidence-based program" as a program that is based on scientific evidence demonstrating that the program model is effective, that is reviewed on site and compared to program model standards by the model developer or the developer's designee at least every five years to ensure that the program continues to maintain fidelity with the program model, and that has had demonstrated and replicated significant and sustained positive outcomes that have been in one or more well-designed and rigorous randomized controlled research designs, and where the evaluation results have been published in a peer-reviewed journal. 4)Defines an "evidence-based home visiting program" as a program AB 50 (Mullin) Page 3 of ? or initiative that does all of the following: a) Meets, on or before April 1, 2015, the U.S. Department of Health and Human Services Maternal, Infant, and Early Childhood Home Visiting criteria, as specified; b) Contains home visiting as a primary service delivery strategy by providers satisfying home visiting program requirements to provide services to families with a pregnant or parenting woman who is eligible for medical assistance; c) Offers services on a voluntary basis to pregnant women, expectant fathers, and parents and caregivers of children from prenatal to five years of age; and, d) Targets participant outcomes that include all of the following: i. Improved maternal and child health. ii. Prevention of child injuries, child abuse or maltreatment, and reduction of emergency department visits. iii. Improvements in school readiness and achievement. iv. Reduction in crime or domestic violence. v. Improvements in family economic self-sufficiency. vi. Improvements in coordination of, and referrals to, other community resources and support. vii. Improvements in parenting skills related to child development. FISCAL EFFECT : According to the Assembly Appropriations Committee: 1)Costs to DHCS in the range of $200,000 to develop the specified plan in consultation with stakeholders. 2)Unknown, significant cost pressure to provide home visiting services through Medi-Cal FFS or managed care (unspecified local/private/potentially General Fund/federal funds). For example, if an additional 1,000 additional women were served, costs would be $5 million to $12 million for services, depending on the program model. Various home visiting program AB 50 (Mullin) Page 4 of ? models may meet the bill's criteria. The funding source is not specified, but the author points out counties, managed care plans, hospitals, foundations, and local First 5 programs all may have interest in funding the program if a structure was in place to accommodate service delivery and leverage federal funds - meaning local or private funding coupled with federal funds may be a viable approach. The state is pursuing an 1115 waiver from the federal government, through which other states have received approval for federal matching funds for home visiting. 3)Home visiting programs have a strong evidence base of outcomes based on randomized controlled trials. To the extent the delivery of home visiting programs is expanded, and assuming the most successful programs are selected: a) Some level of reduced state costs associated with fewer pre-term deliveries, high-risk pregnancies, and childhood injuries in Medi-Cal, and likely reductions in beneficiaries of California Work Opportunity and Responsibility to Kids Program benefits based on better labor market outcomes and less welfare participation among service recipients. b) Cost savings may accrue to counties or school districts based on documented reductions in child abuse and fewer youth crimes, reduced youth substance abuse, and fewer remedial school services. PRIOR VOTES : ----------------------------------------------------------------- |Assembly Floor: |79 - 0 | |------------------------------------+----------------------------| |Assembly Appropriations Committee: |17 - 0 | |------------------------------------+----------------------------| |Assembly Health Committee: |16 - 0 | | | | AB 50 (Mullin) Page 5 of ? ----------------------------------------------------------------- COMMENTS : 1)Author's statement. According to the author, with rising health care costs and an increasing Medi-Cal eligible population across California, there is a need to strengthen the capacity of our current healthcare system to address the health needs of our most vulnerable populations at lower costs. Evidence-based home visiting programs are proven health-based interventions that can improve the health of low-income families in the state, while helping reduce overall costs to our system and improving system outcomes for the state. Voluntary evidence-based home visiting programs - such as NFP, Healthy Families America, Early Head Start (Home Based Option), Parents as Teachers, and Home Instruction for Parents of Preschool Youngsters - strengthen the critical parent-child relationship and connect families with information and resources during the pivotal time from pregnancy to age five. With more than 37 years of evidence from randomized, controlled trials and longitudinal follow-up studies, evidence based home visiting programs have demonstrated sizeable, sustained improvements in maternal health, child health and development, economic stability of families, and helping break intergenerational poverty. By establishing mechanisms for Medi-Cal to increase the reach of home visiting programs, this bill would substantially expand the scale of evidence-based home visiting programs in California. 2)Background. The first California NFP implementing agencies were launched in 1996 in Fresno, Los Angeles, and Alameda Counties using federal Department of Justice funding. NFP provides first-time, low-income mothers with home visitation services by public health nurses. Typically beginning 18 to 28 weeks into their pregnancy, nurses work intensively with mothers to improve prenatal, maternal, and early childhood health and well-being, focusing on therapeutic relationships with the family designed to improve family functioning in health, home and neighborhood environment, family and friend support, parental roles, and major life events. The NFP sites in California have served approximately 9,000 families, of which the majority are Latino. The median age of the mothers is 18 years. Seventy-two percent are enrolled in Medi-Cal, and the median annual household income is $13,500. AB 50 (Mullin) Page 6 of ? NFP has documented outcomes for enrollees, and demonstrated a 23% reduction in cigarette smoking during pregnancy. In addition, of those mothers who entered the program without a high school diploma or General Educational Development Test (GED), 42% had earned their diploma or GED, 25% continued to work toward their diploma or GED, and 15% were pursuing education beyond high school by the time their infants were 24 months old. A 1997 RAND study examined the benefits for children and their families enrolled in early childhood intervention programs. The study found that the NFP generated increased tax revenues from increased employment and earnings, decreased enrollment in public assistance programs, reduced expenditures for education, health, and other services, including special education, emergency room visits, and stays in homeless shelters, and lowered criminal justice system costs. 3)Prior legislation. ACR 155 (Bocanegra, Chapter 144, Statutes of 2014), urges the Governor to identify evidence-based solutions to reduce children's exposure to adverse childhood experiences, address the impacts of those experiences, and invest in preventive health care, mental health and, wellness interventions. AB 543 (Ma, 2010) would have extended, from January 1, 2009 to January 1, 2014, the sunset of the California Children and Families Account (Account). Governor Schwarzenegger vetoed AB 543 stating: "Since the Nurse-Family Partnership program was signed into law in 2006, there have been no private or federal funds received by the state for this program. Since there are no funds to appropriate, there is no need to extend the sunset date for the program's fund account." AB 1829 (Ma, 2008) would have extended, from January 1, 2009, to January 1, 2011, the sunset of the Account. Governor Schwarzenegger vetoed AB 1829, stating: "The historic delay in passing the 2008-2009 State Budget has forced me to prioritize the bills sent to my desk at the end of the year's legislative session. Given the delay, I am only signing bills that are the highest priority for California. This bill does not meet that standard and I cannot sign it at this time." SB 1596 (Runner, Chapter 878, Statutes of 2006) establishes the NFP program administered by the Department of Health Services (now DPH). AB 50 (Mullin) Page 7 of ? 4)Support. Children Now states in support that voluntary early childhood home visiting programs strengthen the critical parent-child relationship and connect families with information and resources during the pivotal time from pregnancy to age five. Extensive research has shown that voluntary home visiting programs increase family self-sufficiency, positive parenting practices, and maternal and child health. Children Now states there is a diverse array of home visiting program models in use, including both nationally-known, intensive program models, as well as locally designed programs intended to engage isolated populations or address other specific local priorities. Many experts hail home visiting program diversity as essential to providing parents with choices, and ensuring that programs are well matched with local needs and strengths. Children Now concludes that it believes this bill can help promote a broad range of home visiting models, reflective of the diverse needs of families and young children in our state. 5)Opposition. The California Right to Life Committee, Inc. (CLRC) writes in opposition that the language in this bill presumes to know better than families how to beget and raise children. CLRC writes the mingling of public and private funds does not represent a republican form of government guaranteed by the U.S. Constitution. CLRC continues that this program is very invasive of family life, and it sees the home-visitation program as one of supposed helpful programs which is foisted on the more vulnerable and less educated family members. SUPPORT AND OPPOSITION : Support: California Nurses Association Children Now First 5 Alameda County First 5 Association of California First 5 California First 5 Solano Children and Families Commission First 5 Sonoma County Commission First 5 Tehama March of Dimes California Chapter Monterey County Board of Supervisors Parents as Teachers Prevent Child Abuse America San Mateo County Board of Supervisors Santa Clara County Board of Supervisors Solano County Board of Supervisors AB 50 (Mullin) Page 8 of ? Oppose: California Right to Life Committee -- END --