By Hyeyoon Cho
When Dulce Garcia’s caregiver called at 8 p.m. one recent night to say she wouldn’t be able to come to work the next day because of a cold, Garcia, who has muscular dystrophy and cannot sit up, feed herself, or turn in bed without assistance, had few options. Her mother, 67, had injured her back. Her father, 77, was dealing with heart failure.
Fortunately, this problem rarely comes up, because Garcia’s aide, Domingo Estela Ramirez, has been a consistent and reliable help for the past five years. But when Ramirez needs time off, Garcia, 43, has turned to the Back Up Provider System (BUPS), a California program of substitute caregivers for older and disabled people on Medi-Cal.
Within three hours of Garcia’s call the next morning, a care worker was at her home in Walnut Park, enabling Garcia to make it to a doctor’s appointment and her job as a patient advocate, translating for Spanish-speaking immigrants at hospitals.
“If it wasn’t for the back up program, most definitely, it would have been a hardship to not have,” Garcia said.
The program also gives Ramirez peace of mind. When she needs to take a day off, she doesn’t have to worry about Garcia going without care. “I feel more at ease knowing she’s being taken care of,” she said through Garcia, who translated from Spanish.
The Back Up Provider System, however, might not survive to the next state budget. Gov. Gavin Newsom is proposing to eliminate BUPS, which would save the general fund about $3.5 million in the next fiscal year and offset a structural deficit in the billions of dollars. The administration also wants to cut about $319 million in other In-Home Support Services that help older and disabled people live more independently.
The BUPS cut represents a small portion of Newsom’s proposed $349 billion budget, which the Legislature and governor’s office are hammering out over the next few weeks. But advocates for those with disabilities say it would come at a cost for the tens of thousands of Medi-Cal recipients in Los Angeles County who could benefit from the service.
What is BUPS?
BUPS launched during the COVID-19 pandemic, when caregivers across the state were falling sick or refusing to work out of fear of infection. It allows recipients of Medicaid’s In-Home Support Services — roughly 875,344 low-income elderly, blind and disabled adults — to call a hotline for an emergency provider when their regular caregiver is unavailable.
In L.A. County, the Personal Assistance Services Council operates the program with seven social workers who staff a call center, matching recipients with trained back-up providers around the clock. To incentivize providers to join the network and respond on short notice, the state pays them $2 above the standard in-home-care hourly wage, which is $19.64 in L.A. County.
The governor’s office said the program is not being used enough to justify its cost.
On average in the 2024-25 fiscal year, roughly 732,000 Californians needed 116 BUPS providers monthly.
Demand for BUPS “has not materialized as expected,” H.D. Palmer, deputy director for external affairs at the state Finance Department, said in an email, adding that the program’s administrative costs are higher than the delivery of program services.
But advocates and recipients argue those statewide numbers mask a more complicated and urgent reality, especially in L.A. County.
Luis Bravo, executive director of the Personal Assistance Services Council — a public authority that connects people with In-Home Support Services — said L.A. County alone accounts for 40% of California’s IHSS population, with over 300,000 recipients. While many counties have struggled to build viable backup registries, Bravo said L.A. has made it work.
Bravo argues that the cost of the program actually saves the state money in emergency room visits that recipients might make for lack of options.
“It’s being used the way it’s supposed to be used, and the money is being allocated properly,” Garcia said, of L.A. County’s handling of the program.
According to data compiled by the Personal Assistance Services Council, during the 2024-25 fiscal year, the program received 1,256 BUPS requests and fulfilled 648 — meaning back-up providers were able to work the requested days and times. Across counties, California Association of Public Authorities data shows that during the same year, over 4,100 requests were submitted to BUPS and almost 2,500 were fulfilled.
The governor’s office said eliminating BUPS reflects “the administration’s regular review of state programs and commitment to utilizing resources effectively.” The administration added that it remains open to conversations with counties and public authorities about how to “efficiently administer backup services to help meet recipients’ urgent needs.”
Enabling people to live at home
Cynde Soto, Personal Assistance Services Council governing board chair, described what her life would be like without it. Paralyzed from the shoulders down, she cannot drink water, regulate her body temperature, eat, or reposition herself without assistance. Her nearest family member lives six hours away.
“I would end up in the emergency room by the end of the day,” she said. “And then in a nursing home.”
Soto worries that if she were to call 911 because she had no backup provider, paramedics might be pulled from other emergencies to help her. She would be taken, she presumes, to an already-strained emergency room, wait hours for a bed, and occupy clinical resources at a cost many times higher than back-up care would have been.
“Why would we want to influx the health provider system when there’s not enough doctors, there’s not enough hospitals?” Bravo said.
In addition to the state-run BUPS, L.A. County runs its own county-funded back-up caregiver option — the Back-Up Attendant Program. But the county-run program is intended for recipients who need at least 25 hours of personal care per week, and it requires back-up caregivers to be certified nurse assistants or have an equivalent certification.
Bravo said BUPS exists for people who do not clear that bar, as there are no certification or minimum hours required for the state program. However, since BUPS is funded entirely by the state and federal governments ($450,000 each, for a total of $900,000 for L.A. County), it makes Los Angeles more vulnerable to cuts than other counties, such as San Francisco, that rely entirely on their own, county-run programs.
Barriers to use
One reason why BUPS may be underused, advocates say, is that those who could benefit from it may not be aware of it. Another reason is the phone system itself. A language barrier may be preventing many from ever making the call, said Justice Pak, a Korean community liaison at a Los Angeles nonprofit that helps people with disabilities and seniors live independently.
“There may be Korean American seniors who use BUPS, but I don’t think there are many cases where they are actively utilizing the system,” Pak said. “Even when a situation arises where their regular care provider cannot come in, the language barrier makes it difficult to contact (Personal Assistance Services Council) and request a replacement. As far as I know, most seniors just endure that gap.”
Pak, whose organization — Communities Actively Living Independent & Free — covers south and central Los Angeles, said the problem extends beyond BUPS: Applying for Medi-Cal, Medicare, and other social services carries the same burden for limited-English-speaking communities.
“Rather than cutting the budget on the grounds that utilization is low, shouldn’t we first be thinking about ways to raise that utilization?” she asked.
Bravo and the Personal Assistance Services Council board have been making that case to state senators and in public hearings. The Senate Democrats released a budget plan in April rejecting all cuts to In-Home Support Services.
“When we stop investing in preventative care, we will end up paying for emergency, acute care that is extremely expensive,” said state Sen. Caroline Menjivar (D–San Fernando Valley), who chairs the budget subcommittee on health and human services. “Cutting these services doesn’t make the need for them disappear, the costs will just appear elsewhere, and more expensive.”
Hyeyoon Cho is a writer with the Investigative Reporting Program at the UC Berkeley Graduate School of Journalism. She covered this story through a grant from The SCAN Foundation.