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 --