The 2022-23 Budget: Public Health Foundational Support

2022-23 BUDGET The 2022-23 Budget: Public Health Foundational Support Summary Public Health Funding Historically Limited. Funding for the California Department of Public Health (CDPH)—the majority of which typically flows to local health jurisdictions (LHJs)—has been largely stagnant since 2007-08 until the COVID-19 pandemic. Pandemic Exposed Gaps and Led to Augmentation Beginning in 2022-23. The pandemic highlighted the critical role of public health systems, but also their understaffing and inadequate information technology (IT) systems and lab capacity. The 2021-22 budget agreement committed ongoing funding of $300 million General Fund for CDPH and LHJs beginning in 2022-23. Governor’s 2022-23 Budget Includes Proposed Spending Plan for the $300 Million. Based on findings and recommendations of a workgroup convened in 2021, the plan would retain $100 million for CDPH and direct $200 million to LHJs. State activities would focus on six core areas, including staff recruitment and training, emergency response, IT, communications, community partnerships, and community health. The plan would require LHJs to dedicate 70 percent of funding for workforce and to submit triennial local public health plans tied to existing Community Health Assessments (CHAs) and Community Health Improvement Plans (CHIPs). Despite Merits, Plan Omits Three Key Objectives. While the spending plan would increase real-time disease surveillance, coordinate regional epidemiological and communications activities, and improve strategic planning, it omits (1) creating a workforce pipeline, (2) strengthening the statewide lab network, and (3) laying out an overarching IT strategy. The Plan Could Have Stronger Oversight of LHJs. As written, the plan does not lay out minimum requirements or goals for LHJs. Tying local plans directly to CHAs and CHIPs (which can encompass goals beyond the purview of public health departments) may not be the best substitute for a more deliberate and consistent type of local plan across LHJs. Issues for Legislative Consideration. As the Legislature reviews the proposal, we suggest: • Asking for More Information. Consider requesting more information about the omitted objectives in the spending plan that we have identified. • Incorporating Better LHJ Oversight. Consider requiring more CDPH management of local plan development and oversight of LHJs’ use of funds. Consider identifying common public health goals that the Legislature would prioritize universally. • Developing Reporting Requirements. We suggest including regular reports to the Legislature on CDPH and LHJ efforts. • Implementing Plan Through Trailer Bill Language. The administration proposes implementing the spending plan through budget bill language. We suggest developing trailer bill language to establish the plan’s requirements. GABRIEL PETEK | LEGISLATIVE ANALYST FEBRUARY 2022 1 2022-23 BUDGET BACKGROUND CDPH Funding Historically Drawn From small portion of the CDPH budget. General Fund Fund Sources Dedicated to Specific Purposes. support typically ebbs and flows year over year Historically, the vast majority of funding support for based on one-time appropriations for specific the California Department of Public Health (CDPH) activities such as Alzheimer’s disease research has come from federal and state special funds. grants or support for sickle cell disease centers. Most of CDPH’s federal funding is grant funding In summary, very little of the funding supporting with strict spending and reporting requirements. the CDPH budget can be used flexibly. For example, federal grants help fund health facility Until the Pandemic, Overall Funding for CDPH certification to receive Medicare and Medicaid Was Stagnant; General Fund Support Had payments. They also fund prevention and response Declined. As shown in Figure 1, between 2007-08, (including vaccination) to infectious diseases, when CDPH became a standalone department including outbreaks of specific diseases (such as (it was formerly a division within the then-Department Zika or COVID-19) and ongoing diseases, such of Health Services), and the onset of the COVID-19 as sexually transmitted diseases and HIV/AIDs. pandemic in 2019-20, the overall CDPH budget was Similarly, CDPH’s state special funds—which relatively stagnant and was about $3.4 billion at its support activities such as childhood lead poisoning peak. General Fund support declined in 2009-10 prevention, tobacco control, genetic disease testing, (during the Great Recession) and was never fully and health facility state licensing—must be spent restored. The most CDPH received from the General only on the specified purpose. In contrast, the Fund prior to the pandemic was in its first year as a General Fund historically has supported a relatively standalone department: $361 million in 2007-08. Figure 1 California Department of Public Health Budget Stagnant Until Pandemic; General Fund Had Declined (In Billions) $8 7 6 5 4 3 2 General Federal, Special, and Other Funds Fund 1 2007-08 08-09 09-10 10-11 11-12 12-13 13-14 14-15 15-16 16-17 17-18 18-19 19-20 20-21a 21-22b 22-23 EstimatedProposed a Amounts do not match those in the Governor's budget as two federal grants were budgeted technically as General Fund; here they are reflected as federal funds. b Also includes $1.6 billion General Fund approved in a supplemental appropriation (Chapter 2 of 2022 [SB 115, Skinner]). 2 LEGISLATIVE ANALYST’S OFFICE 2022-23 BUDGET CDPH Provides Guidance to Local Health to health facilities, schools, businesses, and the Jurisdictions (LHJs). California has 61 LHJs— general public. As the COVID-19 pandemic took 58 county public health departments and three hold, however, the state’s public health systems city public health departments. LHJs carry out quickly became overwhelmed. CDPH and LHJs many of the state’s public health programs, did not have enough staff to respond—let alone for example, by responding to local disease maintain their other public health responsibilities outbreaks and reporting diseases to the state, simultaneously—and IT systems and public health conducting restaurant health inspections, offering lab capacity was quickly exceeded. In addition, immunizations, conducting home visiting, and state and local officials struggled with timely and maintaining vital records. Twenty-eight LHJs consistent public health messaging and guidance, operate a local public health lab (since 1999, particularly in light of changing direction from the 12 local public health labs have closed; LHJs federal government. The pandemic also revealed without their own lab often contract with a that the state’s approach to public health had neighboring local public health lab for services). not enabled the strategic planning that might CDPH provides overall direction for many of the have prepared the system for a crisis of this scale programs carried out at the local level and allocates and breadth. funding to the LHJs to administer the programs. 2021-22 Budget Agreement Pledged Ongoing Large Share of CDPH Budget Provided to General Fund Support Beginning in 2022-23. LHJs. Prior to the pandemic, anywhere between The 2021-22 budget included $3 million General 67 percent and 83 percent of CDPH funding flowed Fund one time for CDPH to conduct a review of to LHJs. (In the 2020-21, 2021-22, and proposed essential public health infrastructure requirements 2022-23 budgets, a larger-than-typical share of using the pandemic as context and to inform funding has gone or is proposed to go to state a proposal in the Governor’s 2022-23 budget. operations for COVID-19 response.) LHJs also The budget agreement also included a commitment receive state-local realignment funding for health to provide CDPH with $300 million General (which includes indigent health care and public Fund ongoing beginning in 2022-23. Using the health). Local governments have some discretion $3 million appropriation for the review, CDPH over how health realignment funds are spent. hired a contractor and formed a “Future of Public In addition, they can supplement state funding Health” workgroup, comprised of state and local for public health from other local sources of public health employees; state employees from the funding and may handle and define public health California Health and Human Services Agency and functions somewhat differently from one another. Department of Finance; and representatives of the Consequently, the state currently does not have County Health Executives Association of California good statewide data on each LHJ’s total public (CHEAC), Health Officers Association of California, health spending. and Service Employees International Union (SEIU). COVID-19 Pandemic Highlighted Critical Role Activities included analyses of existing data and of Public Health System and Exposed Gaps in research; surveys with state and local public Its Current State. A primary statutory responsibility health; and discussions and individual interviews of state and local public health is controlling and with a wide variety of public health practitioners, responding to communicable disease outbreaks. experts, and stakeholders, including state and When COVID-19 first was detected in California, local public health staff, public health lab directors, CDPH and LHJs began to issue public health public health associations, and several advocacy orders; collect reportable disease data; investigate organizations. CDPH completed the review, cases and conduct contact tracing; report producing a memo, “Investments and Capabilities information to the federal Centers for Disease Needed for the Future Public Health System” Control and Prevention (CDC), the Governor, other in September. state agencies, and LHJs; and issue guidance www.lao.ca.gov 3 2022-23 BUDGET GOVERNOR’S BUDGET PROPOSAL The Governor’s budget reflects the agreement Creates Office of Policy and Planning. made last year to provide $300 million General The Office of Policy and Planning would conduct Fund ongoing to CDPH starting in 2022-23. strategic planning to assess current and emerging The Governor’s budget also includes a proposal public health threats. This office also would be for how to allocate those funds and includes basic accountable for use of the funding provided in details in budget bill language. Additional details the spending plan, including by establishing about the proposed plan follow, but at a high level, performance targets and publishing an annual $100 million would be retained for state operations report measuring performance. More broadly, this and $200 million would be directed to LHJs. office would build internal capacity to meet future The first allocation of funds in 2022-23 would be strategic leadership needs. available for expenditure over three years. Provides Regional Support. The plan includes ways to support both state objectives and LHJs Proposed Spending by enhancing regional expertise and activities. Plan for State Operations For example: The proposed spending plan would provide • Establishes a Regional Public Health $100 million for state operations and is built Office. This office, housed at CDPH, would around six foundational areas. The Future of include regional specialists for each of the Public Health workgroup identified these six core five public health officer regions (Bay Area, governmental public health spending areas at Rural North, Greater Sacramento, San the state level that support and complement the Joaquin Valley, and Southern California). work of LHJs, health care providers, and other These regional specialists would provide health-related organizations. (It differentiates expertise in analytics, epidemiology, and “governmental” public health services from communications for smaller LHJs and would public health services that might be provided by assist in standardizing state policy. community-based organizations (CBOs), hospitals, • Adds a Regional Disaster Medical and or other health-related organizations.) Figure 2 Health Specialist to the State’s Mutual shows the funding and positions proposed in the Aid Regions. Currently, each of the state’s spending plan for each of the six core governmental six mutual aid regions have a Regional public health spending areas. Additional highlights of the plan are Figure 2 described below. Increases Staffing. The plan Proposal for State Operations Includes proposes 404 new positions at Support for Six Foundational Spending Areas CDPH, a 15 percent increase 2022-23, General Fund (Dollars in Millions) across the relevant CDPH centers and offices, which had Public Health Governmental Spending Areas Expenditures Positions 2,617 authorized positions as of 1. Workforce Development, Recruitment, and Training $57.9 270 December 1, 2021. CDPH intends 2. Emergency Preparedness and Response 27.6 77 to draft duty statements for the 3. IT, Data Science, and Informatics 0.6 3 404 new positions from January 4. Communications, Public Education, Engagement, 4.5 26 and Behavior Change through May of this year, begin 5. Community Partnerships 2.9 5 advertising positions from May to 6. Community Health Improvement 6.2 23 July, and conduct interviews and Totals $99.6 404 make candidate selections from Note: Amounts may not add to total due to rounding. July to October. IT = information technology. 4 LEGISLATIVE ANALYST’S OFFICE 2022-23 BUDGET Disaster Medical and Health Coordinator and Allocates Funding Based on Local Population two Regional Disaster Medical and Health and Demographics. CDPH would award each LHJ Specialists (whose expertise typically is in a base grant of $350,000. Remaining funding would emergency medical services). CDPH proposes be based proportionally on an LHJ’s share of the to add a third Specialist, whose expertise and state’s population (50 percent of funding); level of background is in public health. poverty (25 percent of funding), and share of black/ African American, Latino, and Native Hawaiian/ Establishes 24/7 Intelligence Hub. This hub Pacific Islander residents (25 percent of funding). would replace the current duty officer program, Requires LHJs to Submit Local Public Health which provides 24-hour coverage to receive Plans. An LHJ’s plan would be aligned with their notifications about emerging public health threats existing Community Health Assessment (CHA) and is staffed by redirected full-time staff who take and Community Health Improvement Plan (CHIP), turns being on duty around the clock. The new including proposed evaluation methods and hub instead would be staffed with dedicated metrics. LHJs must complete CHAs and CHIPs employees and include enhanced surveillance and if they want to seek public health accreditation analytic capabilities to make it more proactive on by a national board. (Accreditation means a emerging threats. It would include better real-time public health department attests to a certain surveillance by having California participate in the level of performance, has capacity to carry out CDC’s National Syndromic Surveillance Program, essential public health services, and adheres to BioSense, which collects patient encounter data certain standards.) Typically, CHAs and CHIPs are from emergency departments and can be used to updated every three to five years. CDPH worked identify health threats by tracking patient symptoms with the California Conference of Local Health before diagnoses are confirmed. California currently Officers (CCLHO), CHEAC, and SEIU to develop is the only state that is not engaged actively this approach. in BioSense. Requires LHJs to Dedicate Majority of the Forms Dedicated Recovery Unit. This unit Funding to Workforce. CDPH would require LHJs would help coordinate health-related recovery to spend 70 percent of their funding on workforce, efforts following emergencies and establish particularly to fill staffing gaps identified during the community recovery guidance. COVID-19 pandemic. Expands State Lab Support. CDPH’s Requires Funding to Augment Existing lab-related activities include operating the state’s Resources. CDPH would require LHJs to sign public health lab and licensing clinical labs written attestations that the new funding does not and personnel. These programs would receive replace existing public health resources. 25 new positions, with increased emphasis on workforce training; genomic sequencing for disease Proposed New Requirement for surveillance; and centralization of key lab functions, Nonprofit Hospital Community Benefit such as safety, regulatory compliance, and Plans quality management. The spending plan proposes a new requirement Proposed Spending Plan for (which would be enforced by the Department Support to LHJs of Health Care Access and Information [HCAI]) CDPH would allocate $200 million annually requiring nonprofit hospitals to direct 25 percent to LHJs. To receive funds, each LHJ would be of their community benefit plan funds to CBOs required to submit a local public health plan by in support of local public health efforts and to July 1, 2023 and every three years thereafter. demonstrate how this spending addresses social determinants of health. (Nonprofit hospitals, in exchange for their tax-exempt status, are required to use some of their resources for community benefits, such as charity care, based on a community needs assessment.) 5 2022-23 BUDGET ASSESSMENT OF SPENDING PLAN Providing more sustained, flexible General In Its Current Form, Spending Plan Fund support for public health was an important Omits Three Key Objectives priority for the Legislature in reaching the 2021-22 Does Not Create a Public Health Workforce budget agreement. The administration lived up Pipeline. The current plan focuses on enhancing to its commitment to examine the future of public recruitment and hiring strategies, promoting interest health, producing a memo with its findings and in working at CDPH, and training and developing recommendations and developing the associated current employees—all important activities to spending plan proposal. Below, we discuss the improve CDPH’s current capacity. However, it merits of the proposal and identify a few issues, does not discuss creating a future public health which, if addressed, we believe would strengthen workforce pipeline despite significantly increasing the plan. staffing resources at the state and local levels. Plan Has Numerous Merits (The Governor’s health-related workforce development proposal—referred to as the Care The spending plan reflects a relatively cohesive Economy Workforce Development Package— approach to improving public health systems in primarily concerns health care delivery rather California. In particular: than public health.) We understand that CDPH did • It is based on quantitative and qualitative not consult with HCAI—the state entity operating input from a wide variety of practitioners and a number of existing health-related workforce stakeholders at both the state and local levels. development programs—noting it did not do • The plan is forward-looking, addressing ways so because HCAI is focused on the health care the department can be more proactive and workforce, rather than the public health workforce. strategic in a cost-effective way. For example, Nevertheless, we think that CDPH likely could learn the Office of Policy and Planning will from HCAI’s experience when it comes to various emphasize evaluation, measurement, and tools and strategies for increasing the supply of strategic planning. potential workers in the health field. • It includes a multifaceted approach to Does Not Strengthen Public Health workforce recruitment and retention, including Laboratory Network Statewide. While the plan several options for internal training, education, enhances state lab activities, it does not include and promotion. The internal professional a clear strategy for integrating the 28 local public development options could help cultivate health labs and the state lab into a cohesive future CDPH leadership. network. CDPH noted that LHJs would have the • It stresses real-time disease and emergency option to use their new flexible funding to hire lab surveillance with a dedicated 24/7 Intelligence staff. The spending plan does not include any Hub and by participating in BioSense. minimum capacity requirements for local public • It provides regional support and coordination, health labs, however. At a higher level, it also does as well as regional resources to fill gaps in not address whether there are enough local public epidemiological, analytic, or communications health labs around the state or how well the existing expertise at smaller LHJs. local public health labs and the state lab work collaboratively as a network. • It applies an equity lens to its proposed funding allocations and activities with a Does Not Yet Include an Overarching goal of reducing health disparities among Information Technology (IT) Strategy. While the all Californians. plan acknowledges the importance of IT for public health activities by recognizing it as one of the foundational governmental public health spending areas, it does not allocate any of the $300 million to 6 LEGISLATIVE ANALYST’S OFFICE 2022-23 BUDGET IT (beyond a specific $548,000 project) and it does assistance. Whether these 19 LHJs would be not include an overarching IT strategy. (A separate able to successfully complete high-quality CHAs proposal would support COVID-19/infectious and CHIPs to form the basis of their local plans disease-related IT systems.) CDPH notes that by July 1, 2023 and how much and what type assessments are being conducted to develop a of support and technical assistance they would comprehensive strategic technology plan and that it need to do so are unclear. If there is another will be hiring a Chief IT Strategist to lead this effort. COVID-19 surge, this could be further complicated. When this proposed strategy will be available and In addition, LHJs with completed CHAs and CHIPs how this future vision would be funded is unclear. likely should update them with lessons from the pandemic, but the extent to which this will be done Oversight and Accountability of or is feasible is unclear. LHJs likely would wait LHJs Could Be Strengthened instead until the next update. The plan indicates that CDPH worked with How Closely Local Plans Must Be Tied to CHEAC, CCLHO, and SEIU to develop the CHAs and CHIPs Is Unclear. Some of the issues, spending plan’s approach for the funding of local goals, and metrics in CHAs and CHIPs can be activities and accountability for the use of funds. broad and extend beyond the direct purview The process for developing and implementing of public health. For instance, they can include local plans, however, remains vague and there are strengthening the health care workforce and untapped opportunities to increase the oversight increasing stable housing options. Consequently, of, and accountability for, the LHJs’ implementation there may not be a direct link between CHAs activities. In particular: and CHIPs and efforts to improve foundational Plan Does Not Include Minimum Public Health public health. Moreover, the time line for updating Goals for LHJs. While the plan notes that CDPH CHAs and CHIPs may not align with local plans. would collaborate with CHEAC, CCLHO, and SEIU The Governor’s proposal does not specify how to to develop minimum requirements for the funding tie CHAs and CHIPs to local plans or whether the and statewide metrics, it currently does not include updates to these plans should be aligned. any stated public health goals that every LHJ Plan Lacks Common Standards. The proposed should achieve. We recognize the importance of plan does not specify whether CDPH will provide LHJs having greater flexibility over the use of funds guidance, templates, or examples of what LHJs than they do in the current environment. However, should include in their local plans. Each LHJ may the Legislature may have some specific goals for have slightly different goals or planned activities. local public health, even if it does not prescribe the However, whether all 61 local plans will define way LHJs must achieve them. categories similarly or use consistent methods to Plan Assumes Nearly One-Third of LHJs Can measure progress is unclear. Quickly Develop a CHA and CHIP. Budget bill Plan Does Not Address Coordination of language would require LHJs’ plans to be tied State and Local Public Health Messaging. to their CHAs and CHIPs, including evaluation Although LHJs have discretion and legal authority methods and metrics. According to CDPH, 22 LHJs for various public health activities in their are accredited already and 20 LHJs actively are jurisdictions, the COVID-19 pandemic demonstrated seeking accreditation, meaning they have a CHA the risk of having too many mixed messages from and CHIP or are in the process of developing them. governmental public health authorities. While the This means that up to 19 LHJs are not accredited regional support of communications for smaller nor seeking it, and thus may not have a CHA and LHJs makes sense, the plan does not discuss what CHIP in place already. (An LHJ could have a CHA steps the state and LHJs might be able to take or CHIP, but not seek accreditation.) CDPH said it more broadly to improve and coordinate public would require LHJs to prepare them if they do not health communications statewide. already have them and would provide technical 7 2022-23 BUDGET Plan Does Not Specify How CDPH Will Basic Plan Details Are in Budget Bill Report Back to the Legislature Language, Rather Than Trailer Bill As written, the proposed spending plan does Language not require any reporting to the Legislature about Trailer bill language would allow the Legislature the implementation of the plan or whether CDPH more opportunity to provide policy direction and LHJs are meeting their identified performance about the $300 million augmentation for public indicators. CDPH told our office it will report to the health foundational support and would ensure the Legislature at budget hearings. While we support augmentation is ongoing. Budget bill language, having such testimony and opportunities for on the other hand, provides only limited detail and oversight, the Legislature might want to consider concerns appropriations made over the single having a more formalized means of reporting. budget year, meaning the $300 million still would be We discuss this issue further below. in question in the next budget cycle. ISSUES FOR LEGISLATIVE CONSIDERATION Based on our assessment, we raise several could request that CDPH produce a more specific issues for legislative consideration below. In sum, time line for this strategy and its associated the proposed spending plan for $300 million deliverables and seek a description of the steps presents a promising approach to improving the administration will undertake to develop the state’s governmental public health systems. this strategy. The issues we raise below, if addressed, offer Improving LHJ Oversight Issues opportunities to strengthen certain aspects of the spending plan and increase legislative oversight. The current plan does not provide much detail about, or direction to, LHJs about CDPH’s Addressing the Spending Plan’s expectations for LHJs’ use of the $200 million Missing Pieces in funding. The Legislature could consider The Legislature could consider asking the the following. administration for more information about the Refining Process for Preparing Local Plans. plan’s missing elements and how these elements The Legislature might consider whether the potentially could be incorporated in a revised proposal to have LHJs’ local plans tied to CHAs spending plan. Specifically, the Legislature could and CHIPs should be refined. For example, it could ask about the following issue areas: instead consider requiring CDPH to develop a Workforce Pipeline and Integrated template and provide associated guidance and State-Local Public Health Lab Network. examples for all LHJs to use. This not only would The Legislature could ask the administration provide greater consistency (making statewide how these elements could be incorporated in the review and evaluation easier), but also it would spending plan and how much these elements ensure that the proposed activities and targets were could cost. The Legislature then could consider practicable for a public health department. These whether it wishes to augment funding to support local plan submissions could be informed by the these activities or reduce funding for some aspects CHAs and CHIPs, even if not tied to them directly. of the plan. Identifying Specific Requirements for LHJs. An IT Strategic Plan. While the spending The Legislature might wish to identify specific plan does not currently reflect a strategic plan requirements for LHJs that it would prioritize for IT-related expenditures, CDPH indicated it universally in local public health. For example, the will be developing an IT strategy after hiring a Legislature could require that LHJs meet specific Chief IT Strategist. Nevertheless, the Legislature goals or spend a minimum level of funding for 8 LEGISLATIVE ANALYST’S OFFICE 2022-23 BUDGET specific purposes, such as increasing local public • Annual updates about the $300 million health lab capacity. We think the Legislature could spending plan (which could be presented add such parameters without unduly impeding at budget hearings), including discussion of local flexibility to address local public health needs progress toward full implementation of the and challenges. core spending areas; updates on various Developing Accountability System. initiatives in the plan, such as development The administration’s proposed plan does not and implementation of statewide performance specify how LHJs would be held accountable targets; updates on strategic IT planning and for making progress toward plan metrics. projects; how it is holding LHJs accountable The Legislature could consider whether CDPH for making progress toward local plan metrics should be tasked with providing additional supports and status of LHJs meeting these targets; to LHJs that are not meeting outlined objectives. and a basic summary of the state of the state’s public health. These updates also Increasing Legislative could address public health communications Reporting Requirements challenges across state and local public health systems and how these might be ameliorated. The Legislature might want to consider specific reporting from CDPH to increase its oversight of the • Five-year and/or ten-year reviews about the $300 million spending plan, but also to increase its state of state’s public health, which could understanding of emerging public health issues. include progress toward meeting identified The Legislature could: performance and outcome indicators (set by the Legislature), including reducing health Require Interim Reporting to the Legislature disparities, challenges facing state and local Throughout Year One. This could include reporting public health, and key data and information on: hiring numbers, status of internal training and about ongoing and emerging or anticipated educational opportunities, status of the LHJ plans future public health issues. The administration (especially in the counties currently without CHAs could request funding for these reviews and and CHIPs), and other implementation challenges. we recommend the Legislature require that Require Informal and Formal Reporting to the they be conducted by an unbiased third party, Legislature at Specific Intervals on an Ongoing such as an academic or research institution. Basis. The Legislature could consider additional types of reporting to increase oversight and Shift Implementing Language From awareness of key public health issues and threats. Budget Bill Language to Trailer Bill This could include, for example: An augmentation and policy of this magnitude • Informal reporting to the Legislature when should be handled in trailer bill language. potential public health threats reach a We suggest the Legislature require the particular threshold. administration to add the plan’s implementing language to trailer bill. 9 2022-23 BUDGET 10 LEGISLATIVE ANALYST’S OFFICE 2022-23 BUDGET 11 2022-23 BUDGET LAO PUBLICATIONS This report was prepared by Sonja Petek, and reviewed by Mark C. Newton and Carolyn Chu. 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, California 95814. 12 LEGISLATIVE ANALYST’S OFFICE