The 2019-20 Budget: Governor's Proposals for Infants and Toddlers With Special Needs

The 2019-20 Budget: Governor’s Proposals for Infants and Toddlers With Special Needs GABRIEL PETEK LEGISLATIVE ANALYST FEBRUARY 2019 Summary Weaknesses of California’s Early Intervention System Identified in Prior LAO Report. California provides early intervention services to about 50,000 infants and toddlers with either a disability (such as a visual or hearing impairment) or a significant developmental delay (such as not beginning to speak or walk when expected). These services are provided under three programs administered by two agencies: regional centers and schools. Our recent report, Evaluating California’s System for Serving Infants and Toddlers With Special Needs, identified several weaknesses with the state’s early intervention system, including: persistent service delays, poorly coordinated transitions between regional center early intervention and school-based special education services, and large differences between the amount of funding and parental choice offered to families served by schools and regional centers. Governor’s Budget Includes Three Proposals Related to Early Intervention Services. First, the Governor proposes $60 million ongoing (split between Proposition 56 [2016] tobacco tax revenues and federal Medicaid funding) to provide supplemental payments to physicians who screen children covered by Medi-Cal for developmental delays. Second, the Governor proposes four new positions (at a cost of $446,000 General Fund) to increase state oversight of regional center early intervention services. Finally, the Governor expresses concerns about transitioning children from regional center early intervention services to school-based preschool services at age three and indicates forthcoming trailer bill language may seek to improve these transitions. Proposed Supplemental Payments Not a Cost-Effective Option for Serving More Children. Many factors potentially contribute to some children who are eligible for early intervention services going without such services. The Governor’s proposed supplemental payments address one such potential factor—the possibility that some children covered by Medi-Cal are not being screened for developmental delays. However, current state policies already require Medi-Cal plans to provide such screenings and cover associated costs. Under the Governor’s proposal, the state would essentially pay twice for services it already requires. We recommend rejecting this proposal and instead focusing on more cost-effective options for serving more children, such as better enforcement of existing Medi-Cal requirements or providing supplemental payments to providers willing to serve children in their families’ homes (and thereby decreasing the number of parents unable to find a nearby provider of early intervention services). Governor’s Other Proposals Are Reasonable, Recommend Adopting Alongside Broader Reforms. The Governor’s proposals to increase state oversight of regional centers and improve preschool transition planning represent promising first steps towards addressing some of the systemic weaknesses identified in our recent report. However, we recommend the Legislature also consider broader reforms (in particular, consolidating all early intervention services under a single agency) to fully address these weaknesses. analysis full gutter 2019-20 BUDGET The Governor’s budget includes three proposals build off our recent report, Evaluating California’s relating to services for infants and toddlers System for Serving Infants and Toddlers With with special needs. In this report, we provide Special Needs. We conclude this report with a overarching background on the state’s system for discussion of the extent to which the Governor’s serving such children and then describe and assess proposals overall address the deficiencies identified the Governor’s proposals regarding developmental in that report. We then recommend a path forward screenings, state oversight of regional centers, and for the Legislature. preschool transitions. These assessments largely BACKGROUND California Serves About 50,000 Infants and education specialist who provides support on Toddlers With Special Needs. In 2017-18, a wide range of developmental issues. California provided early intervention services to • Identification of Providers. Staff help parents 47,500 infants and toddlers with special needs identify appropriate providers for the services (by 2019-20, this number is expected to exceed listed in the plan. 56,000). These infants and toddlers either have a • Service Provision. Direct service providers disability (such as a visual or hearing impairment) typically provide services in the child’s home, or a significant developmental delay (such as not alongside the child’s parents (or other primary beginning to speak or walk when expected). The caregiver). This practice is intended to ensure state’s early intervention system provides these parents learn how to promote their child’s infants and toddlers with services such as speech development as part of their daily routines. (In therapy and home visits focused on helping parents some cases, services might be provided in a promote their child’s development. clinical or group setting.) Federal Law Establishes a General Research Finds Several Benefits From Framework for Early Intervention Services. As Specific Early Intervention Programs. Many a condition of receiving federal early intervention studies have rigorously identified positive impacts funding, California adheres to a five-step process from specific early intervention programs. These established by Part C of the Individuals With programs are typically designed to address Disabilities Education Act (IDEA). specific developmental challenges—for example, • Referral. Primary care physicians typically children with severe autism—and sometimes refer infants and toddlers following routine require relatively intensive supports (in some cases, checkups. In addition, parents may seek out 20 hours or more of professional therapy per week). services directly. Studies generally find such programs promote • Evaluation. Following each referral, specialists development in early years while reducing the need evaluate the child and speak to the parents for intensive supports later in life. to determine eligibility for early intervention Unclear Whether Federal Early Intervention services. Framework Is Sufficient to Produce These Same • Individualized Family Service Plan. The Benefits. Although studies have documented family of a child deemed eligible for services benefits for a variety of specific early intervention meets with staff to develop an individualized programs, there are reasons to doubt such family service plan. These plans are reviewed benefits extend to all programs offered under the at least once every six months. Typically, very broadly-crafted federal early intervention these plans include authorization for targeted framework. For example, the services offered services such as weekly speech therapy under that framework typically range in intensity sessions and regular home visits from an early from about 1 to 4 hours of professional therapy 2 LEGISLATIVE ANALYST’S OFFICE analysis full gutter 2019-20 BUDGET per week, notably less than the 20 hours per week Regional Centers Administer Most of offered by some programs with well-documented California’s Early Intervention Services. Figure 2 benefits. Researchers have yet to rigorously (see next page) illustrates the relative proportions document the benefits of the federal framework. of infants and toddlers currently served in each of Federal Law Leaves Two Important Policy California’s three early intervention programs. The Decisions Up to the States. Within IDEA’s basic regional center early intervention program is named framework, the federal government allows states to Early Start and accounts for most children served. make two important policy decisions. Regional Centers Coordinate Services From Outside Providers. Although schools typically • Eligibility. Federal law requires states to employ their own early intervention service serve all children with specific disabilities providers (such as speech therapists), regional or “significant developmental delays,” but centers coordinate services from and enter into allows each state to define what constitutes contracts with independent providers. Such a significant delay. Researchers generally providers include specialists in private practice categorize each state’s eligibility criteria as and nonprofits dedicated to early intervention. broad, moderate, or narrow. California’s In addition, some regional centers contract with current eligibility is considered broad and schools to provide early intervention services. is estimated to apply to roughly 20 percent of the state’s infants and toddlers. About half of the Figure 1 states have eligibility criteria as broad as (or broader In California, Two Agencies Administer than) California’s, whereas Three Early Intervention Programs the other half have more targeted criteria. (Between Regional Centers 2009 and 2015, the state temporarily restricted eligibility due to fiscal constraints.) • Administration. Each state may decide which Early Start: Regional Centers serve all eligible specific agency to entrust children not otherwise served in a school-based with serving all eligible program. children. Some states delegate this responsibility to a human services agency, whereas others rely on local schools. As Figure 1 shows, California has Schools adopted a uniquely complex patchwork of three programs operated by both schools Legacy Program: A total HVO Program: All schools of 97 schools that have must serve any infant or (under the direction of the historically served infants toddler with only a hearing, California Department of and toddlers continue to visual, or orthopedic (HVO) receive state funding to impairment but no other Education) and regional serve about 5,000 eligible eligible condition or centers (under the direction children. developmental delay. of the Department of Developmental Services, or DDS). www.lao.ca.gov 3 analysis full gutter 2019-20 BUDGET • Early Intervention Services. Figure 2 Medi-Cal pays for some early Regional Centers Serve Most intervention services authorized Infants and Toddlers With Special Needs by regional centers. State law 2017-18 requires regional centers to help families access services covered by their health insurance— including Medi-Cal—before using regional center funding to pay for early intervention services. The most common early intervention services covered by Medi-Cal include speech, physical, and Regional Centers occupational therapies. (Early Start) 41,000 Despite Following Federal Framework, the State Funds Most Early Intervention Schools (HVO Services. After tapping into health Program) insurance (which we estimate 1,500 provides roughly $60 million annually), California covers most Schools (Legacy Program) remaining early intervention costs 5,000 with a combination of targeted state and federal funding. Figure 3 Children With Only HVO All Other Eligible Children shows state and federal funding Impairments 45,000 in 2018-19 for early intervention 2,500 services in California. Even though HVO = hearing, visual, or orthopedic impairments. the federal government sets the basic framework for early intervention services, the state Medi-Cal Supports Early Intervention in Two provides the majority of targeted Ways. About half of California’s infants and toddlers funding for these programs ($504.5 million in state are covered by Medi-Cal, the state’s Medicaid funding as compared to $51.5 million in federal program, which is supported by both state and funding). federal funding. Medi-Cal supports California’s early Regional Centers Subject to State Oversight. intervention system in two ways. Once every three years, DDS reviews each • Regular Developmental Screenings. of California’s 21 regional centers for their Medi-Cal requires regular developmental performance in administering early intervention screenings for enrolled children. However, services. When a review finds a regional center is because physicians often do not consistently not consistently meeting federal early intervention report the specific services they provide, requirements (for example, when a regional center the state does not know how often this is not ensuring services begin soon after children requirement is followed and thus how many are deemed eligible), the center is required to children currently receive developmental develop a corrective action plan. screenings in Medi-Cal. 4 LEGISLATIVE ANALYST’S OFFICE analysis full gutter 2019-20 BUDGET Service Provider Rates Paid Figure 3 by Regional Centers Have State Provides Most Targeted Funding for Been Largely Frozen for Many Early Intervention Years. In response to state budget constraints, state law LAO Estimates for 2018‑19a (In Millions) effectively froze rates for existing Fund Source Amount Early Start providers in 2003 and Regional Centers: Early Start capped rates for new providers State Non-Proposition 98 General Fund $424.2 at the statewide median rate in Federal IDEA Part C Grant 37.3 2008. Rates have largely been Subtotal ($461.5) unchanged since that time, aside Schools: Legacy Program from one overall increase in 2016 State Proposition 98 General Fund $77.8 and ongoing adjustments to Subtotal ($77.8) account for rising state minimum Schools: HVO Program wage costs. A forthcoming rate Federal IDEA Part C Grant $14.2 study (which concerns rates paid State Proposition 98 General Fund 2.4 to a variety of service providers Subtotal ($16.6) in the regional center system, Total $555.9 including those in Early Start), will a Does not include (1) Early Start services billed to Medi-Cal and private insurance, (2) Early Start services reimbursed by federal Early Periodic Screening and Diagnosis and Treatment funding, or likely recommend adjustments (3) general purpose K-12 funds locally repurposed to support school-based early intervention. to these rates when the study is IDEA = Individuals With Disabilities Education Act and HVO = hearing, visual, or orthopedic submitted to the Legislature on impairments. March 1. GOVERNOR’S PROPOSALS Below, we describe, assess, and offer associated Proposition 56 tobacco tax revenues and federal recommendations for the three proposals from the funding for Medi-Cal. Notably, state policy currently Governor related to early intervention. We then requires Medi-Cal managed care plans to provide provide an overall assessment of the Governor’s such screenings, and thus, some portion of the package of early intervention proposals and offer an proposed one million screenings currently occurs associated recommendation. and would occur even absent the Governor’s proposal. (The vast majoirity of children enrolled in DEVELOPMENTAL SCREENINGS Medi-Cal are in managed care plans.) Assessment Governor Proposes $60 Million Ongoing to Increase Screenings for Developmental California Likely Serves Only a Small Delays. Under the Governor’s proposal, physicians Proportion of Children Eligible for Early serving children in Medi-Cal would receive Intervention. The administration believes expanded supplemental payments to screen these children screenings would allow California to identify and for developmental delays. The administration serve more children with developmental delays. estimates $60 million would support about one Researchers agree that many eligible children are million screenings annually. (The proposed $60 rate not currently served, although (as we discuss in per screening is equal to the rate currently paid greater detail below) it is not clear whether this is for developmental screenings administered primarily due to a lack of screenings. In 2017-18, under Medi-Cal fee-for-service.) Associated we estimate California provided early intervention costs would be covered by a combination of to about 4 percent of its infants and toddlers. www.lao.ca.gov 5 analysis full gutter 2019-20 BUDGET Some researchers believe roughly 20 percent of provide services in the families’ homes (as California’s infants and toddlers are eligible for encouraged by federal law), or whose clinics early intervention under the state’s current eligibility are within reasonable travel distances. criteria. Governor’s Proposal Addresses One of These Failing to Serve All Eligible Children Five Reasons, But This May Not Be the Most Contravenes Federal Requirements, Raises Important One. Of these five factors listed above, Equity Concerns. Although federal law allows the Governor’s proposal only addresses the issue states to establish their own eligibility criteria for of inconsistency in the provision of developmental early intervention, it requires each state to identify screenings. Unfortunately, we do not have sufficient and serve all children meeting these state-specific data to determine whether this factor plays an criteria. This requirement is intended to ensure especially large role in preventing eligible children states treat similar children similarly. Because from being served, or whether any of the other California does not identify and serve all eligible four factors are more significant. In conversations children, it may treat similar children dissimilarly, with stakeholders and experts, many told us that serving some children with specific developmental they are particularly concerned about the likelihood challenges but not serving others with the exact parents will either not follow through on physician same challenges. referrals or become discouraged before their There Are at Least Five Possible Reasons children receive services. The administration has California Does Not Serve All Eligible Children. not provided a compelling rationale for devoting In conversations with stakeholders and experts, resources solely to developmental screenings rather we were made aware of at least five major reasons than to addressing the other four reasons children why some eligible children do not receive early go unserved. intervention services. Under Governor’s Proposal, State Would • First, some children do not receive regular Pay Twice for Services It Already Requires. physician checkups. In contracting for Medi-Cal managed care plans, the state requires these plans to follow certain • Second, some physicians do not consistently federal guidelines calling for regular developmental screen children for developmental challenges. screenings of all children ages birth through three. • Third, some physicians do not refer all Because such screenings are already required, the potentially eligible children for formal state builds at least a portion of associated costs evaluations (in some instances because these into the per-child payment that Medi-Cal managed physicians are unfamiliar with the state’s early care plans receive on behalf of enrolled children. intervention system or misunderstand its The Governor’s proposal would thus provide eligibility criteria). supplemental payments for an activity managed • Fourth, some parents do not follow through care plans are already required to arrange and for on physicians’ referrals (in some instances which they are already compensated. For managed because they hope their children will grow out care plans that base their reimbursement off of their developmental challenges). Medi-Cal fee-for-service, the Governor’s proposal • Fifth, some parents who try to follow through would exactly double the total payment currently on referrals become discouraged before their provided for these screenings. (Although the state children receive services. In some instances, sometimes provides supplemental payments for this is because the evaluation process itself other services required by managed care plans, is time-consuming or difficult to understand. such as well-child visits, the administration has In other instances, parents may become not provided a compelling rationale for doing so in discouraged even after their children are this case, and specifically has not demonstrated deemed eligible for services because they this proposal is the most cost-effective approach are unable to find providers who accept their to identifying more children with developmental insurance (including Medi-Cal), are willing to delays.) 6 LEGISLATIVE ANALYST’S OFFICE analysis full gutter 2019-20 BUDGET Governor’s Budget Does Not Account for compared to alternative solutions for identifying the Cost of Serving More Children. Although the more children with developmental delays. We administration believes the proposed supplemental recommend the Legislature consider alternative payments for developmental screenings will result strategies for identifying and providing early in more eligible children being identified for early intervention services to more children. Such intervention, the Governor’s budget provides no strategies can be tailored to each of the five factors additional funding to serve these children once currently preventing some eligible children from identified. If the Governor’s proposal resulted in being served, and may include: more eligible children being served, the associated • Pursuing policies to increase the number of cost increase could total hundreds of millions children receiving regular checkups. of dollars annually (for example, if the number • Increasing enforcement of existing requirement of children served increased 50 percent, the that children in Medi-Cal managed care plans associated Early Start costs to serve these children receive regular developmental screenings, would be about $250 million). for example by including developmental California May Not Have Enough Providers screenings in the state’s public accountability to Serve All Eligible Children. Although we are measures that summarize and compare uncertain how many additional children would end Medi-Cal managed care plan performance. up receiving early intervention services because In addition, since the state already provides of the administration’s proposal (since we do not a supplemental payment for well-child visits, have good provider data about the number of it could make that supplemental payment screenings already occurring), we caution that any contingent upon the concurrent delivery of a effort to serve more children may be complicated developmental screening. by a shortage of qualified providers. Regional • Better educating physicians about the early centers indicate they already have difficulty finding intervention system, in particular its eligibility providers to serve current caseloads. Although requirements and how to make a referral. the state could address relatively small shortages by increasing provider rates (which have not been • Assisting parents in following through on increased on a regular basis for many years), physician referrals. addressing larger shortages might require long-term • Increasing provider rates or providing strategies such as expanding training programs and supplemental payments to providers willing to attracting more candidates into relevant fields. serve children in their families’ homes, thereby decreasing the number of parents unable to Recommendation find a nearby provider. Reject Governor’s Proposal, Develop Serving More Children Will Increase State Strategy for Identifying All Eligible Children. Costs. If the state managed to identify and serve California already requires and has mechanisms all eligible children, associated service costs would to automatically pay for Medi-Cal plans to provide likely increase by hundreds of millions of dollars. developmental screenings to all children. While In addition, the state may have to develop a supplemental payments may be appropriate in concurrent strategy to address potential provider situations where other program improvement shortages which might otherwise preclude serving strategies are likely to fail, the administration all eligible children. Depending on how such a has not provided a compelling reason to provide strategy was structured, it too may increase state supplemental payments as opposed to pursuing costs by tens of millions of dollars. We recommend alternative solutions. At $60 million in total the Legislature consider these costs when projected costs, the Governor’s proposal to constructing its overall budget. introduce additional, supplemental payments for these screenings is very likely not cost-effective www.lao.ca.gov 7 analysis full gutter 2019-20 BUDGET STATE OVERSIGHT OF Increased Oversight Might Partially Address Service Delays . . . Currently, DDS reviews each REGIONAL CENTERS regional center once every three years to ensure it Governor Proposes Increasing State is meeting federal early intervention requirements. Oversight of Regional Centers’ Early Start When it finds that a regional center is struggling Programs. Citing concerns about the number of to meet federal deadlines or otherwise falling children eligible for Early Start services failing to short of federal requirements, that regional center receive these services within federally-mandated is required to develop a corrective action plan. time lines, the Governor proposes adding four Increasing the frequency of these reviews to full-time positions at DDS (at a cost of $446,000 once every two years, as the Governor’s budget General Fund) to increase monitoring of regional proposes, might further encourage some regional center Early Start programs from once every three centers to address long-standing deficiencies. years to once every two years. . . . But Eliminating Service Delays Likely Requires Broader Reform. Given the scope and Assessment persistence of California’s struggles with providing California Continues to Lag Other States timely early intervention services, we do not believe in Providing Timely Services. Because, absent the Governor’s proposal goes far enough. In our support, babies developing a few days behind recent evaluation, we suggested California’s uniquely their peers might grow into toddlers who are complicated early intervention system (under which several months or even a year behind, federal law two agencies operate three separate programs) requires that services begin soon after children are likely generates some confusion and contributes determined eligible for early intervention. In our to service delays. Administrative consolidation may recent evaluation of California’s early intervention therefore produce more timely services. system, we found California does worse than Recommendation most other states in meeting federal deadlines for service delivery. Since publishing our evaluation, we Adopt Governor’s Proposal, Consider Broader received updated data for California which indicate Administrative Reform. The Governor’s proposal the state has improved somewhat on meeting to increase state oversight of regional centers’ these deadlines but still does notably worse than Early Start programs appears reasonable and may most states were doing in their most recent data. improve—albeit modestly—the state’s problems with Figure 4 summarizes the available data. service delays. However, we continue to encourage the Legislature to consider consolidating all early intervention Figure 4 programs under a single agency, California Does Poorly in Meeting Federal Deadlines as we believe this would be the single most important step towards Percentage of Children for Which State Completed Activities on Timea eliminating service delays. If Develop Initial services were consolidated under Service Plan Begin Services regional centers, it could potentially 2013-14 result in state savings in the low 25th Ranked State 97.9% 98.3% tens of millions of dollars which 40th Ranked State 95.1 94.6 could be repurposed to serve more Californiab 82.1 82.1 eligible children. If services were 2014-15 consolidated under schools, on California 85.5% 88.8% the other hand, it could potentially a An initial service plan is to be developed within 45 days of referral. Services are to begin within 45 days of an initial service plan. result in significant added costs b In 2013-14, California ranked 46th among the 50 states in meeting the initial service plan deadline potentially reaching the low and 47th in meeting the begin services deadline. Data from the 49 states are not yet available for 2014-15. hundreds of millions of dollars. 8 LEGISLATIVE ANALYST’S OFFICE analysis full gutter 2019-20 BUDGET PRESCHOOL TRANSITIONS Recommendation Governor Expresses Concern About Establish Best Practices to Improve Preschool Transitions, Formal Proposal May Be Preschool Transition. We recommend the Forthcoming. In the 2019-20 Governor’s Budget Legislature adopt legislation requiring regional summary, the administration expresses an intent centers to exercise a series of best practices to “pursue statewide policies” to improve the regarding preschool transitions. These best transitions from Early Start to preschool special practices could include having regional centers education services for three-year olds with special develop annual inter-agency agreements with needs. Although the Governor’s budget includes each school in their service area to specify the no specific proposal fulfilling this intent, the general process for handling preschool transitions, administration indicates that future actions may identify a specific point of contact at each include relevant trailer bill language. school for coordinating all transitions, implement shared data systems to allow both agencies to Assessment track children nearing their third birthdays, and develop a process for summer months when California Continues to Perform Worse schools are typically closed. We believe these Than Other States in Facilitating Preschool recommendations could be accomplished either by Transitions. Many children who qualify for early reprioritizing existing resources or with a relatively intervention are also eligible to receive special modest increase in regional center funding in the education from their local schools when they turn low millions of dollars. three. To ensure a smooth transition between early intervention and special education services, federal law requires states to begin planning such transitions Figure 5 no later than 90 days before California Does Poorly in Planning each child’s third birthday. In our Preschool Transitions recent evaluation of California’s Percentage of Children for Which State Completed Activities on Timea early intervention system, we Notify Hold Planning Develop found California does worse than School Conference Transition Plan most other states in satisfying these federal requirements. 2013-14 25th Ranked State 99.7% 98.0% 99.3% Since publishing our evaluation, 40th Ranked State 94.3 90.7 94.4 we received updated data for Californiab 74.5 86.2 91.4 California (though not from the 2014-15 other 49 states) which indicate the California 76.1% 87.9% 80.4% state has made little progress in a Deadline for all activities is 90 days before child’s first birthday. meeting the deadlines associated b In 2013-14, California ranked 47th among the 50 states in notifying schools about impending with this transition. Figure 5 transitions, 44th in holding planning conferences, and 47th in developing transition plans. Data from the 49 states are not yet available for 2014-15. summarizes the available data. A PATH FORWARD Governor’s Proposals Come in the Wake Toddlers With Special Needs, identified significant of Recent LAO Evaluation of State’s Early weaknesses in California’s early intervention Intervention System. Our recent report, Evaluating system. These included persistent service delays, California’s System for Serving Infants and poorly coordinated transitions between Early Start www.lao.ca.gov 9 analysis full gutter 2019-20 BUDGET and preschool special education services, and Recommendation for Development of large differences between the amount of funding Comprehensive Strategy and parental choice offered to families served by Develop Comprehensive Strategy for State’s schools and regional centers. Below, we evaluate Early Intervention System. Given the notable the Governor’s package of early intervention weaknesses of the state’s current early intervention proposals in the context of our earlier findings and system, we recommend the Legislature revisit other recent research. the two major policy decisions it made in first Governor’s Proposals Respond to Some establishing this system more than 30 years ago. Weaknesses in California’s Early Intervention System . . . Specifically, the Governor’s proposals • Eligibility. Although California now has a to increase regional center monitoring and improve long experience with relatively broad eligibility preschool planning are intended to address criteria, it has yet to identify and serve all persistent concerns regarding service delays and eligible children. Serving all eligible children preschool transitions. may require a substantial increase in state . . . But Leave Others Untouched. Most funding as well as a concerted strategy to notably, the Governor’s budget does not address address provider shortages. the large differences between the amount of • Administration. As we discussed in our funding and parental choice offered to families previous report, we believe the state’s served by schools and regional centers. bifurcated early intervention system has several weaknesses, including service delays and unjustified differences between school-based and regional center programs. We recommend the state consider options for moving towards a unified system. LAO PUBLICATIONS This report was prepared by Ryan Anderson, Ben Johnson, and Sonja Petek, and reviewed by Mark C. Newton. The Legislative Analyst’s Office (LAO) is a nonpartisan office that provides fiscal and policy information and advice to the Legislature. To request publications call (916) 445-4656. This report and others, as well as an e-mail subscription service, are available on the LAO’s website at www.lao.ca.gov. The LAO is located at 925 L Street, Suite 1000, Sacramento, CA 95814. 10 LEGISLATIVE ANALYST’S OFFICE