Existing law establishes the licensure and regulation of health facilities by the State Department of Public Health, including, among others, general acute care hospitals. A violation of these provisions is a crime. Under existing law, a general acute care hospital is required to provide certain basic services, including medical, nursing, surgical, anesthesia, laboratory, radiology, pharmacy, and dietary services. Existing law authorizes a general acute care hospital to provide various special or supplemental services if certain conditions are met. Existing regulations define a supplemental service as an organized inpatient or outpatient service that is not required to be provided by law or regulation. Existing law requires a health facility to provide 90 days of public notice, with specified requirements, of the proposed closure or elimination of a supplemental service, such as maternity services.

This bill would require an acute care hospital that operates a perinatal unit and expects challenges in the next 6 months that may result in a reduction or loss of perinatal services, to report specified information to the Department of Health Care Access and Information, including, but not limited to, the number of medical staff and employees working in the perinatal unit and the hospitals prior performance on financial metrics. The bill would require the Department of Health Care Access and Information to forward the provided information to the State Department of Health Care Services and the State Department of Public Health. The bill would require this information to be kept confidential to the extent permitted by law. The bill would require, within 3 months of receiving this notice from the hospital, the Department of Health Care Access and Information, in conjunction with the State Department of Public Health and the State Department of Health Care Services, to conduct a community impact assessment to identify the 3 closest hospitals operating a perinatal unit, their distance from the challenged facility, and whether those hospitals have any restrictions on their reproductive health services. The bill would require the Department of Health Care Access and Information to provide the community impact assessment to specified entities and would require these entities to keep the community impact assessment confidential. If the hospital plans to close its perinatal unit, the bill would require the hospital to provide public notice of the proposed closure, including the results of the community impact assessment, and other specified information on the hospitals internet website 90 days in advance of the closure. The bill would require the public to be permitted to comment on the closure for 60 days after the notice is given, and would require one noticed public hearing be conducted by the hospital. The bill would also require the hospital to accept written public comment. By creating a new crime, this bill would impose a state-mandated local program.

Existing constitutional provisions require that a statute that limits the right of access to the meetings of public bodies or the writings of public officials and agencies be adopted with findings demonstrating the interest protected by the limitation and the need for protecting that interest.

This bill would make legislative findings to that effect.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law establishes the licensure and regulation of health facilities by the State Department of Public Health, including, among others, general acute care hospitals. A violation of these provisions is a crime. Under existing law, a general acute care hospital is required to provide certain basic services, including medical, nursing, surgical, anesthesia, laboratory, radiology, pharmacy, and dietary services. Existing law authorizes a general acute care hospital to provide various special or supplemental services if certain conditions are met. Existing regulations define a supplemental service as an organized inpatient or outpatient service that is not required to be provided by law or regulation. Existing law requires a health facility to provide 90 days of public notice, with specified requirements, of the proposed closure or elimination of a supplemental service, such as maternity services.

This bill would require an acute care hospital that operates a perinatal unit and expects challenges in the next 6 months that may result in a reduction or loss of perinatal services, to provide report specified information to the Department of Health Care Access and Information, including, but not limited to, the number of medical staff and employees working in the perinatal unit and the hospitals prior performance on financial metrics. The bill would require the Department of Health Care Access and Information to forward the provided information to various entities, including the State Department of Health Care Services. Services and the State Department of Public Health. The bill would require this information be kept confidential to the extent permitted by law. The bill would require, within 3 months of receiving this notice from the hospital, the Department of Health Care Access and Information, in conjunction with the State Department of Public Health and the State Department of Health Care Services, to conduct a community impact assessment to identify the 3 closest hospitals operating a perinatal unit, their distance from the challenged facility, and whether those hospitals have any restrictions on their reproductive health services. The bill would require the Department of Health Care Access and Information to provide the community impact assessment to specified entities and would require these entities to keep the community impact assessment confidential. If the hospital closes plans to close its perinatal unit, the bill would require the hospital to provide public notice of the proposed closure, including the results of the community impact assessment, and other specified information on the hospitals internet website 90 days in advance of the closure. The bill would require the public to be permitted to comment on the closure for 60 days after the notice is given, and would require at least one noticed public hearing be conducted by the hospital. The bill would also require the hospital to accept written public comment. By creating a new crime, this bill would impose a state-mandated local program.

Existing constitutional provisions require that a statute that limits the right of access to the meetings of public bodies or the writings of public officials and agencies be adopted with findings demonstrating the interest protected by the limitation and the need for protecting that interest.

This bill would make legislative findings to that effect.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law establishes the licensure and regulation of health facilities by the State Department of Public Health, including, among others, general acute care hospitals. A violation of these provisions is a crime. Under existing law, a general acute care hospital is required to provide certain basic services, including medical, nursing, surgical, anesthesia, laboratory, radiology, pharmacy, and dietary services. Existing law authorizes a general acute care hospital to provide various special or supplemental services if certain conditions are met. Existing regulations define a supplemental service as an organized inpatient or outpatient service that is not required to be provided by law or regulation. Existing law requires a health facility to provide 90 days of public notice, with specified requirements, of the proposed closure or elimination of a supplemental service, such as maternity services.

This bill would require an acute care hospital that offers maternity services, when those services are at risk of closure, as defined, in the next 6 months operates a perinatal unit and expects challenges in the next 6 months that may result in a reduction or loss of perinatal services, to provide specified information to the Department of Health Care Access and Information as well as the State Department of Public Health, Information, including, but not limited to, the number of medical staff and employees working in the maternity ward perinatal unit and the hospitals prior and projected performance on financial metrics. The bill would require the Department of Health Care Access and Information to forward the provided information to various entities, including the State Department of Health Care Services. The bill would require this information be kept confidential to the extent permitted by law. The bill would require, within 6 3 months of receiving this notice from the hospital, the Department of Health Care Access and Information, in conjunction with the State Department of Public Health, Health and the State Department of Health Care Services, to conduct a community impact assessment to determine identify the 3 closest hospitals offering maternity services in the geographic area and operating a perinatal unit, their distance from the at-risk facility. The challenged facility, and whether those hospitals have any restrictions on their reproductive health services. The bill would require the Department of Health Care Access and Information to provide the community impact assessment to specified entities and would require these entities to keep the community impact assessment confidential. If the hospital closes its perinatal unit, the bill would require the hospital to provide public notice of the potential closure, including the results of the community impact assessment, and other specified information on the hospitals internet website 90 days in advance of the proposed closure. The bill would require the public to be permitted to comment on the potential closure for 60 days after the notice is given, and would require at least one noticed public hearing be conducted by the hospital. The bill would also require the hospital to accept written public comment. By creating a new crime, this bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law establishes the licensure and regulation of health facilities by the State Department of Public Health, including, among others, general acute care hospitals. A violation of these provisions is a crime. Under existing law, a general acute care hospital is required to provide certain basic services, including medical, nursing, surgical, anesthesia, laboratory, radiology, pharmacy, and dietary services. Existing law authorizes a general acute care hospital to provide various special or supplemental services if certain conditions are met. Existing regulations define a supplemental service as an organized inpatient or outpatient service that is not required to be provided by law or regulation. Existing law requires a health facility to provide 90 days of public notice, with specified requirements, of the proposed closure or elimination of a supplemental service, such as maternity services.

This bill would require an acute care hospital that offers maternity services, when those services are at risk of closure, as defined, in the next 12 6 months to provide specified information to the Department of Health Care Access and Information as well as the State Department of Public Health, including, but not limited to, the number of medical staff and employees working in the maternity ward and the hospitals prior and projected performance on financial metrics. The bill would require this information be kept confidential to the extent permitted by law. The bill would require, within 6 months of receiving this notice from the hospital, the Department of Health Care Access and Information, in conjunction with the State Department of Public Health, to conduct a community impact assessment to determine the 3 closest hospitals offering maternity services in the geographic area and their distance from the at-risk facility. The bill would require the hospital to provide public notice of the potential closure, including the results of the community impact assessment, and other specified information on the hospitals internet website 90 days in advance of the proposed closure. The bill would require the public to be permitted to comment on the potential closure for 60 days after the notice is given, and would require at least one noticed public hearing be conducted by the hospital. The bill would also require the hospital to accept written public comment. By creating a new crime, this bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law establishes the licensure and regulation of health facilities by the State Department of Public Health, including, among others, general acute care hospitals. A violation of these provisions is a crime. Under existing law, a general acute care hospital is required to provide certain basic services, including medical, nursing, surgical, anesthesia, laboratory, radiology, pharmacy, and dietary services. Existing law authorizes a general acute care hospital to provide various special or supplemental services if certain conditions are met. Existing regulations define a supplemental service as an organized inpatient or outpatient service that is not required to be provided by law or regulation. Existing law requires a health facility to provide 90 days of public notice, with specified requirements, of the proposed closure or elimination of a supplemental service, such as maternity services.

This bill would express the intent of the Legislature to enact legislation to address maternity ward closures. require an acute care hospital that offers maternity services, when those services are at risk of closure, as defined, in the next 12 months to provide specified information to the Department of Health Care Access and Information as well as the State Department of Public Health, including, but not limited to, the number of medical staff and employees working in the maternity ward and the hospitals prior and projected performance on financial metrics. The bill would require this information be kept confidential to the extent permitted by law. The bill would require, within 6 months of receiving this notice from the hospital, the Department of Health Care Access and Information, in conjunction with the State Department of Public Health, to conduct a community impact assessment to determine the 3 closest hospitals offering maternity services in the geographic area and their distance from the at-risk facility. The bill would require the hospital to provide public notice of the potential closure, including the results of the community impact assessment, and other specified information on the hospitals internet website 90 days in advance of the proposed closure. The bill would require the public to be permitted to comment on the potential closure for 60 days after the notice is given, and would require at least one noticed public hearing be conducted by the hospital. The bill would also require the hospital to accept written public comment. By creating a new crime, this bill would impose a state-mandated local program.

Existing law establishes the licensure and regulation of health facilities by the State Department of Public Health, including, among others, general acute care hospitals.

This bill would express the intent of the Legislature to enact legislation to address maternity ward closures.

GOVERNOR'S VETO

GV Bill Id:AB 1895

Author:(Weber)

As Enrolled Ver:September 4, 2024

2/3 vote

SUMMARY

Requires a general acute care hospital (GACH) that operates a perinatal unit and determines those services are at risk of closing in the next six months to report specified information to the Department of Health Care Access and Information (HCAI). Requires HCAI, the Department of Public Health (DPH), and the Department of Health Care Services (DHCS) to assess the potential impact to the community and develop recommendations for how to resolve the perinatal units' challenges.

Senate Amendments

1. Require HCAI to provide a community impact assessment based on a GACHs report in conjunction with DHCS and DPH. Requires the information provided to be kept confidential to the extent permitted by applicable law.
2. Remove the Legislature from the hospital's notification to the departments described in 1) above, when experiencing challenges.
3. Require both the GACH and the departments to determine what intervention is needed, if any, to keep the perinatal unit open.

Governor’s Veto Message

This bill would require a hospital to report specified information to the Department of Health Care Access and Information (HCAI) if it expects challenges in the next six months that could result in a reduction or loss of perinatal services, and would require HCAI, the Department of Public Health (CDPH), and Department of Health Care Services (DHCS) to conduct a community impact assessment using the reported information.

I share the author's concern for communities that may lose access to perinatal care, as labor and delivery unit closures have become more common in recent years and this availability is important for positive pregnancy outcomes. For this reason, working with the Legislature, we have taken many steps to assist these units in remaining open. For example, we provided $300 million for the Distressed Hospital Loan Program to offer interest-free loans to hospitals in financial distress and directed billions of dollars from the managed care organization (MCO) tax towards Medi-Cal provider rate increases. However, current law already requires hospitals to provide public notice in advance of a supplemental service elimination, and much of the information in the proposed community impact report is duplicative. Further, this bill creates costly administrative burdens for the state that are unlikely to change hospitals' business decisions.

COMMENTS

1. Supplemental Services. With some exceptions, GACHs are required to provide eight basic services: medical, nursing, surgical, anesthesia, laboratory, radiology, pharmacy, and dietary. Beyond these basic services, hospitals can be authorized to offer supplemental services, including outpatient services such as emergency services, or inpatient services such as intensive care, cardiovascular surgery, maternity, and a psychiatric unit, among others.
2. Increasing Maternity Unit Closures. On November 15, 2023, CalMatters published an investigative story focusing on the increase in maternity unit closures in California, titled "As Hospitals Close Labor Wards, Large Stretches of California Are Without Maternity Care." According to this report, from 2012 to 2019, at least 19 hospitals stopped offering labor and delivery services (six of those were because the hospitals closed completely). In an acceleration, 16 more closed maternity services from 2020 to 2022. By the time of publication, 11 more had announced maternity closures in 2023, including one hospital that completely closed (Madera Community Hospital). CalMatters reported that after El Centro Regional Medical Center closed its maternity service in January of 2023, Imperial County was left with only one hospital doing births for the approximately 2,500 babies born every year in Imperial County. In total, according to the CalMatters analysis, at least 46 California hospitals have shut down or suspended labor and delivery since 2012, and 27 of those have taken place in the last three years. Twelve rural counties do not have any hospitals delivering babies, and Latino and low-income communities have been hit hardest by losses. CalMatters noted that the closures come as the country and state contend with a maternal mortality crisis, with pregnancy-related deaths reaching a 10-year high in 2020 in California. The CalMatters report stated that hospital administrators cite a number of reasons for the closures, including high costs, labor shortages, and declining birth rates.
3. Effects of Maternity Ward Closures. A 2018 study published by the Journal of the American Medical Association showed that rural counties not adjacent to urban areas fare the worst with the loss of hospital-based obstetric services. For these counties, maternity ward closures were associated with increases in out-of-hospital and preterm births and births in hospitals without obstetric units in the following year. The latter "emergency births" in unprepared facilities also occurred in urban-adjacent counties. The Association of State and Territorial Health Organizations notes that the effect of hospital closures goes well beyond isolated negative health consequences, including the exacerbation of poor socioeconomic conditions, job loss, transportation barriers, and overall higher health care costs for disadvantaged communities. A study set for publication in April 2024 shows that obstetric closures have a nuanced impact on communities, depending on the size and rurality of the community. For example, in far northern counties, birthing people take the understood risk of giving birth while making the long drive to their obstetric facility. Others, in more urban communities may face other negative impacts not otherwise revealed without a specific impact assessment.
4. Current Process for Closing an Emergency Department Requires an Impact Evaluation. Under existing law, while most supplemental services only require a 90 day notice, hospitals are required to provide at least a 180 day notice prior to a planned reduction or elimination of the level of emergency medical services to DPH, the local health department, and all health plans or other entities under contract with the hospital to provide services to enrollees. A separate provision of law, which permits a hospital to surrender a license or permit with the approval of DPH, specifies that "before approving a downgrade or closure of emergency services," the county or the local emergency medical services agency is required to conduct an impact evaluation of the downgrade or closure upon the community, and how that downgrade or closure will affect emergency services provided by other entities. This impact evaluation is required to incorporate at least one public hearing, and must be done within 60 days of DPH receiving notice of the intent to downgrade or close emergency services. Despite the language stating "before approving a downgrade or closure of emergency services," DPH has not interpreted this provision of law as giving them the ability to deny a hospital the ability to close or reduce emergency services, and therefore the impact evaluation is more of a tool to help the community and the local emergency services agency prepare for the reduction or closure.

According to the Author

Last November, CalMatters published an article on the issue of maternity ward closures. In that story, they found that between 2012 and 2019, at least 19 California hospitals stopped offering labor and delivery services. Six of those hospitals closed completely. That number rose when sixteen more hospitals closed their maternity wards between 2020 and 2022. Under current law, the state is only notified once a decision to close a maternity unit has already been made. Without prior notification, the state has no opportunity to intervene when possible, or consider these facts when making policy and budget decisions.

Arguments in Support

The American College of Obstetricians and Gynecologists District IX (ACOG) is the sponsor of this bill and states that it creates a process to better inform decision makers and the public when a facility may be in jeopardy of closing its labor and delivery unit and to provide the opportunity to prevent the closure or mitigate its impact. ACOG notes that requiring facilities to report on the number of births, staffing levels, and fiscal condition will provide valuable data to better understand the challenges the labor and delivery units face. It will also enable targeted interventions to support the sustainability of labor and delivery units and ensure that every family has access to safe, quality maternal care.

Arguments in Opposition

The Department of Finance is opposed to this bill as it results in ongoing General Fund costs not accounted for in the State's fiscal plan.

FISCAL COMMENTS

According to the Senate Appropriations Committee, unknown, ongoing General Fund costs for HCAI, DPH, and DHCS for state administration.

VOTES

ASM HEALTH: 13-1-2

YES: Bonta, Waldron, Aguiar-Curry, Arambula, Wendy Carrillo, Haney, Jones-Sawyer, Maienschein, McCarty, Rodriguez, Santiago, Schiavo, Weber

NO: Sanchez

ABS, ABST OR NV: Flora, Joe Patterson

ASM APPROPRIATIONS: 11-3-1

YES: Wicks, Arambula, Bryan, Calderon, Wendy Carrillo, Mike Fong, Grayson, Haney, Hart, Pellerin, Villapudua

NO: Sanchez, Dixon, Ta

ABS, ABST OR NV: Jim Patterson

ASSEMBLY FLOOR: 64-1-15

YES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Juan Carrillo, Wendy Carrillo, Chen, Connolly, Davies, Mike Fong, Garcia, Gipson, Grayson, Haney, Hart, Irwin, Jackson, Jones-Sawyer, Kalra, Lackey, Lee, Low, Lowenthal, Maienschein, McCarty, McKinnor, Muratsuchi, Stephanie Nguyen, Ortega, Pacheco, Papan, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Rendon, Reyes, Luz Rivas, Rodriguez, Blanca Rubio, Santiago, Schiavo, Soria, Ting, Valencia, Villapudua, Waldron, Wallis, Ward, Weber, Wicks, Wilson, Wood, Zbur, Robert Rivas

NO: Essayli

ABS, ABST OR NV: Cervantes, Megan Dahle, Dixon, Flora, Vince Fong, Friedman, Gabriel, Gallagher, Holden, Hoover, Mathis, Jim Patterson, Joe Patterson, Sanchez, Ta

SENATE FLOOR: 31-7-2

YES: Allen, Archuleta, Ashby, Atkins, Becker, Blakespear, Bradford, Caballero, Cortese, Dodd, Durazo, Eggman, Glazer, Gonzalez, Hurtado, Laird, Limón, McGuire, Menjivar, Min, Newman, Padilla, Portantino, Roth, Rubio, Skinner, Smallwood-Cuevas, Stern, Umberg, Wahab, Wiener

NO: Alvarado-Gil, Grove, Jones, Nguyen, Niello, Seyarto, Wilk

ABS, ABST OR NV: Dahle, Ochoa Bogh

ASSEMBLY FLOOR: 70-0-9

YES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Juan Carrillo, Wendy Carrillo, Chen, Connolly, Davies, Flora, Mike Fong, Friedman, Gabriel, Garcia, Gipson, Grayson, Haney, Hart, Holden, Hoover, Irwin, Jackson, Jones-Sawyer, Kalra, Lackey, Lee, Low, Lowenthal, Maienschein, Mathis, McCarty, McKinnor, Muratsuchi, Stephanie Nguyen, Pacheco, Papan, Joe Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Rendon, Reyes, Luz Rivas, Rodriguez, Blanca Rubio, Santiago, Schiavo, Soria, Ting, Valencia, Villapudua, Waldron, Wallis, Ward, Weber, Wicks, Wilson, Wood, Zbur, Robert Rivas

ABS, ABST OR NV: Cervantes, Megan Dahle, Dixon, Essayli, Gallagher, Ortega, Jim Patterson, Sanchez, Ta

UPDATED

VERSION: September 4, 2024

CONSULTANT: Lara Flynn / HEALTH / (916) 319-2097 FN: 0005143

CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 1895

Author:(Weber)

As Amended Ver:August 23, 2024

Majority vote

SUMMARY

Requires a general acute care hospital (GACH) that operates a perinatal unit and determines those services are at risk of closing in the next six months to report specified information to the Department of Health Care Access and Information (HCAI). Requires HCAI, the Department of Public Health (DPH), and the Department of Health Care Services (DHCS) to assess the potential impact to the community and develop recommendations for how to resolve the perinatal units' challenges.

Senate Amendments

1. Require HCAI to provide a community impact assessment based on a GACHs report in conjunction with DHCS and DPH. Requires the information provided to be kept confidential to the extent permitted by applicable law.
2. Remove the Legislature from the hospital's notification to the departments described in 1) above, when experiencing challenges.
3. Require both the GACH and the departments to determine what intervention is needed, if any, to keep the perinatal unit open.

COMMENTS

1. Supplemental Services. With some exceptions, GACHs are required to provide eight basic services: medical, nursing, surgical, anesthesia, laboratory, radiology, pharmacy, and dietary. Beyond these basic services, hospitals can be authorized to offer supplemental services, including outpatient services such as emergency services, or inpatient services such as intensive care, cardiovascular surgery, maternity, and a psychiatric unit, among others.
2. Increasing Maternity Unit Closures. On November 15, 2023, CalMatters published an investigative story focusing on the increase in maternity unit closures in California, titled "As Hospitals Close Labor Wards, Large Stretches of California Are Without Maternity Care." According to this report, from 2012 to 2019, at least 19 hospitals stopped offering labor and delivery services (six of those were because the hospitals closed completely). In an acceleration, 16 more closed maternity services from 2020 to 2022. By the time of publication, 11 more had announced maternity closures in 2023, including one hospital that completely closed (Madera Community Hospital). CalMatters reported that after El Centro Regional Medical Center closed its maternity service in January of 2023, Imperial County was left with only one hospital doing births for the approximately 2,500 babies born every year in Imperial County. In total, according to the CalMatters analysis, at least 46 California hospitals have shut down or suspended labor and delivery since 2012, and 27 of those have taken place in the last three years. Twelve rural counties do not have any hospitals delivering babies, and Latino and low-income communities have been hit hardest by losses. CalMatters noted that the closures come as the country and state contend with a maternal mortality crisis, with pregnancy-related deaths reaching a 10-year high in 2020 in California.

The CalMatters report stated that hospital administrators cite a number of reasons for the closures, including high costs, labor shortages, and declining birth rates. In the past 30 years, the number of births have dropped by half in California, and the birth rate is at its lowest level on record. CalMatters noted that the trend is not unique to California, with labor and delivery units closing across the country. Many closures result from hospital systems consolidating maternity care into one location, which hospitals argue can help maintain staff training and provide a higher level of care. According to CalMatters, labor and delivery units are often the second-most expensive department for hospitals to run, second only to emergency rooms, and quoted a health researcher as stating that obstetrics units are often unprofitable for hospitals to operate. As recently as February 8, 2024, Adventist Health Simi Valley announced it was closing its labor and delivery department and neonatal intensive care unit effective May 8, 2024. Adventist stated that births had declined by 25% at the hospital and it could no longer sustain the service. Adventist noted that Ventura County births dropped from 19 per 1,000 in 1990 to 10.5 per 1,000 in 2021.

1. Effects of Maternity Ward Closures. A 2018 study published by the Journal of the American Medical Association showed that rural counties not adjacent to urban areas fare the worst with the loss of hospital-based obstetric services. For these counties, maternity ward closures were associated with increases in out-of-hospital and preterm births and births in hospitals without obstetric units in the following year. The latter "emergency births" in unprepared facilities also occurred in urban-adjacent counties. The Association of State and Territorial Health Organizations notes that the effect of hospital closures goes well beyond isolated negative health consequences, including the exacerbation of poor socioeconomic conditions, job loss, transportation barriers, and overall higher health care costs for disadvantaged communities. A study set for publication in April 2024 shows that obstetric closures have a nuanced impact on communities, depending on the size and rurality of the community. For example, in far northern counties, birthing people take the understood risk of giving birth while making the long drive to their obstetric facility. Others, in more urban communities may face other negative impacts not otherwise revealed without a specific impact assessment.
2. Current Process for Closing an Emergency Department Requires an Impact Evaluation. Under existing law, while most supplemental services only require a 90 day notice, hospitals are required to provide at least a 180 day notice prior to a planned reduction or elimination of the level of emergency medical services to DPH, the local health department, and all health plans or other entities under contract with the hospital to provide services to enrollees. A separate provision of law, which permits a hospital to surrender a license or permit with the approval of DPH, specifies that "before approving a downgrade or closure of emergency services," the county or the local emergency medical services agency is required to conduct an impact evaluation of the downgrade or closure upon the community, and how that downgrade or closure will affect emergency services provided by other entities. This impact evaluation is required to incorporate at least one public hearing, and must be done within 60 days of DPH receiving notice of the intent to downgrade or close emergency services. Despite the language stating "before approving a downgrade or closure of emergency services," DPH has not interpreted this provision of law as giving them the ability to deny a hospital the ability to close or reduce emergency services, and therefore the impact evaluation is more of a tool to help the community and the local emergency services agency prepare for the reduction or closure.

According to the Author

Last November, CalMatters published an article on the issue of maternity ward closures. In that story, they found that between 2012 and 2019, at least 19 California hospitals stopped offering labor and delivery services. Six of those hospitals closed completely. That number rose when sixteen more hospitals closed their maternity wards between 2020 and 2022. Under current law, the state is only notified once a decision to close a maternity unit has already been made. Without prior notification, the state has no opportunity to intervene when possible, or consider these facts when making policy and budget decisions.

Arguments in Support

The American College of Obstetricians and Gynecologists District IX (ACOG) is the sponsor of this bill and states that it creates a process to better inform decision makers and the public when a facility may be in jeopardy of closing its labor and delivery unit and to provide the opportunity to prevent the closure or mitigate its impact. ACOG notes that requiring facilities to report on the number of births, staffing levels, and fiscal condition will provide valuable data to better understand the challenges the labor and delivery units face. It will also enable targeted interventions to support the sustainability of labor and delivery units and ensure that every family has access to safe, quality maternal care.

Arguments in Opposition

The Department of Finance is opposed to this bill as it results in ongoing General Fund costs not accounted for in the State's fiscal plan.

FISCAL COMMENTS

According to the Senate Appropriations Committee, unknown, ongoing General Fund costs for HCAI, DPH, and DHCS for state administration.

VOTES:

ASM HEALTH: 13-1-2

YES: Bonta, Waldron, Aguiar-Curry, Arambula, Wendy Carrillo, Haney, Jones-Sawyer, Maienschein, McCarty, Rodriguez, Santiago, Schiavo, Weber

NO: Sanchez

ABS, ABST OR NV: Flora, Joe Patterson

ASM APPROPRIATIONS: 11-3-1

YES: Wicks, Arambula, Bryan, Calderon, Wendy Carrillo, Mike Fong, Grayson, Haney, Hart, Pellerin, Villapudua

NO: Sanchez, Dixon, Ta

ABS, ABST OR NV: Jim Patterson

ASSEMBLY FLOOR: 64-1-15

YES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Juan Carrillo, Wendy Carrillo, Chen, Connolly, Davies, Mike Fong, Garcia, Gipson, Grayson, Haney, Hart, Irwin, Jackson, Jones-Sawyer, Kalra, Lackey, Lee, Low, Lowenthal, Maienschein, McCarty, McKinnor, Muratsuchi, Stephanie Nguyen, Ortega, Pacheco, Papan, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Rendon, Reyes, Luz Rivas, Rodriguez, Blanca Rubio, Santiago, Schiavo, Soria, Ting, Valencia, Villapudua, Waldron, Wallis, Ward, Weber, Wicks, Wilson, Wood, Zbur, Robert Rivas

NO: Essayli

ABS, ABST OR NV: Cervantes, Megan Dahle, Dixon, Flora, Vince Fong, Friedman, Gabriel, Gallagher, Holden, Hoover, Mathis, Jim Patterson, Joe Patterson, Sanchez, Ta

SENATE FLOOR: 31-7-2

YES: Allen, Archuleta, Ashby, Atkins, Becker, Blakespear, Bradford, Caballero, Cortese, Dodd, Durazo, Eggman, Glazer, Gonzalez, Hurtado, Laird, Limón, McGuire, Menjivar, Min, Newman, Padilla, Portantino, Roth, Rubio, Skinner, Smallwood-Cuevas, Stern, Umberg, Wahab, Wiener

NO: Alvarado-Gil, Grove, Jones, Nguyen, Niello, Seyarto, Wilk

ABS, ABST OR NV: Dahle, Ochoa Bogh

UPDATED

VERSION: August 23, 2024

CONSULTANT: Lara Flynn / HEALTH / (916) 319-2097 FN: 0004693

 THIRD READING  

Bill No: AB 1895

Author: Weber (D), et al.

Amended: 8/23/24 in Senate

Vote: 21

SENATE HEALTH COMMITTEE: 9-2, 7/3/24

AYES: Roth, Glazer, Gonzalez, Hurtado, Limón, Menjivar, Rubio, Smallwood-Cuevas, Wiener

NOES: Nguyen, Grove

SENATE APPROPRIATIONS COMMITTEE: 4-2, 8/15/24

AYES: Caballero, Ashby, Becker, Wahab

NOES: Jones, Seyarto

NO VOTE RECORDED: Bradford

ASSEMBLY FLOOR: 64-1, 5/21/24 - See last page for vote

SUBJECT: Public health: maternity ward closures

SOURCE: American College of Obstetricians and Gynecologists District IX

California Nurse-Midwives Association

Reproductive Freedom for All California

DIGEST:

This bill requires a hospital that operates a perinatal unit, and expects challenges in the next six months that may result in a reduction or loss of perinatal services, to make a report to the Department of Health Care Access and Information (HCAI), and requires HCAI to forward this report to relevant state departments and to the Chairs of the Senate and Assembly Health Committees, but otherwise requires this report to be kept confidential. Requires HCAI to do a community impact assessment of a potential closure within 90 days of receiving a report from a hospital, and to share this impact assessment with state agencies and the two policy committee chairs, but otherwise requires this impact assessment to be kept confidential unless the hospital announces a closure of the perinatal services.

Senate Floor Amendments of 8/23/24 remove the Legislature from the hospital’s notification, and require both the hospital and the state to determine what state intervention is needed, if any, to keep the perinatal unit open.

ANALYSIS:

Existing law:

1. Licenses and regulates health facilities by the California Department of Public Health (CDPH), including general acute care hospitals, acute psychiatric hospitals, skilled nursing facilities, and intermediate care facilities, among others. [Health and Safety Code (HSC) §1250, et seq.]
2. Requires any hospital that provides emergency medical services (EMS) to provide notice of a planned reduction or elimination of the level of EMS to CDPH, the local government entity in charge of the provision of health services, and all health care service plans or other entities under contract with the hospital, as soon as possible but not later than 180 days prior to the planned reduction or elimination of emergency services. Requires the hospital to also provide public notice, within the same time limits, in a manner that is likely to reach a significant number of residents of the community serviced by that facility. [HSC §1255.1]
3. Specifies that a hospital is not subject to the notice requirements in 2) above if CDPH determines that the use of resources to keep the emergency center open substantially threatens the stability of the hospital as a whole, or if CDPH cites the emergency center for unsafe staffing practices. [HSC §1255.1(c)]
4. Requires a health facility implementing a downgrade or change to make reasonable efforts to ensure that the community served by its facility is informed of the downgrade or closure, including advertising the change in terms likely to be understood by a layperson, soliciting media coverage regarding the change, informing patients of the facility of the impending change, and notifying contracting health plans. [HSC §1255.2]
5. Permits a health facility license holder, with the approval of CDPH, to surrender its license or special permit for suspension or cancellation by CDPH. Requires CDPH, before approving a downgrade or closure of emergency services, to receive a copy of an impact evaluation by the county to determine impacts of the closure or downgrade on the community. Permits the county to designate the local EMS agency as the appropriate agency to conduct the impact evaluation. Requires development of the impact evaluation to incorporate at least one public hearing, and requires the impact evaluation and hearing to be completed within 60 days of the county receiving notification of intent to downgrade or close emergency services. [HSC §1300]
6. Requires a general acute care hospital or acute psychiatric hospital, not less than 120 days prior to closing the facility, or 90 days prior to eliminating a supplemental service, or relocating a supplemental service to a different campus, to provide public notice, containing specified information, of the proposed closure, elimination, or relocation, including a notice posted at the entrance to all affected facilities and a notice to CDPH and the board of supervisors of the county in which the health facility is located. Requires the notice to include, among other items, a description of the three nearest available comparable services in the community. [HSC §1255.25]
7. Excludes county facilities from the public notice requirements of 6) above, as county facilities are subject to separate provisions of law requiring counties to provide public notice and public hearings when proposing to eliminate or reduce the level of medical services provided by a county, or when selling or transferring management of these service. This process is known as the Beilenson Act. [HSC §1442.5]
8. Establishes the Department of Health Care Access and Information (HCAI), and among other responsibilities, designates HCAI as the state agency designated to collect health facility data for use by all state agencies, including various financial data reports. [HSC §127000, et seq. and §128730]

This bill:

1. Requires a hospital that operates a perinatal unit, and expects challenges in the next six months that may result in a reduction or loss of perinatal services, to report the following information to HCAI:
   1. The number of medical staff and employees working in the perinatal unit;
   2. The number of deliveries per month over the past 12 months in the perinatal unit;
   3. The number of patients served in the perinatal unit over the past 12 months who had commercial insurance, Medi-Cal, or Medicare;
   4. The hospital’s prior performance on financial metrics from the past 12 months;
   5. The factors that have caused challenges in the perinatal unit; and,
   6. What is needed for the perinatal unit to remain open, and whether state intervention is needed.
2. Requires HCAI to forward the hospital’s report to the Department of Health Care Services (DHCS) and CDPH.
3. Requires the information in the report to be kept confidential to the extent permitted by applicable law.
4. Requires a hospital, when determining whether it is expecting challenges and is required to submit the report in 1) above, and when developing the report, to consider financial challenges, difficulties finding and retaining qualified workforce members, decreased demand for perinatal services, and birth volume.
5. Requires HCAI, in conjunction with CDPH and DHCS, upon receipt of a report from a hospital under the provisions of this bill, to assess the potential impact to the community served of a closure of the hospital’s perinatal unit, develop recommendations for how to resolve the perinatal unit’s challenges, and determine whether state assistance is warranted and feasible.
6. Requires HCAI’s community impact assessment to identify the three closest hospitals operating a perinatal unit, their distance from the challenged facility, and whether those hospitals have any restrictions on their reproductive health services.
7. Requires the community impact assessment to be completed within three months of receipt of the report from the hospital, and requires HCAI to provide the community impact assessment to the hospital, DHCS, and CDPH.
8. Requires the community impact assessment, notwithstanding any other law, to be kept confidential by all recipients, unless the perinatal unit is closed.
9. Requires a hospital, if it plans to close its perinatal unit, to provide public notice of the proposed closure in accordance with Existing Law 6), and to include the results of the community impact assessment. Requires the notice to be posted on the hospital’s website 90 days in advance of the closure, requires the public to be permitted to comment on the closure for 60 days after the notice is given, and requires one noticed public hearing to be conducted by the hospital within the 60 day public comment period.
10. Prohibits a violation of this bill from serving as the basis for an administrative penalty under existing provisions of law providing for administrative assessments for violations of the laws governing licensed hospitals.

Comments

1. Author’s statement. According to the author, “last November, CalMatters published an article on the issue of maternity ward closures. In that story, they found that between 2012 and 2019, at least 19 California hospitals stopped offering labor and delivery services. Six of those hospitals closed completely. That number rose when sixteen more hospitals closed their maternity wards between 2020 to 2022. After El Centro Regional Medical Center closed its maternity ward in January, Imperial County has only one hospital left delivering babies. Under current law, the state is only notified once a decision to close a maternity unit has already been made. Without prior notification, the state has no opportunity to intervene when possible, or consider these facts when making policy and budget decisions. Alternatively, this bill requires hospitals to notify the state when their maternity unit is at risk of closure.”
2. Background on perinatal units in hospitals. With some exceptions, general acute care hospitals are required to provide eight basic services: medical, nursing, surgical, anesthesia, laboratory, radiology, pharmacy, and dietary. Beyond these basic services, hospitals can be authorized to offer supplemental services, including outpatient services such as emergency services, or inpatient services such as intensive care, cardiovascular surgery, perinatal units, and psychiatric units, among other supplemental services.
   
   Perinatal units are defined in regulations as a maternity and newborn service of the hospital for the provision of care during pregnancy, labor, delivery, postpartum, and neonatal periods with appropriate staff, space, equipment and supplies. The regulations pertaining to the required staff for perinatal units specify that a physician certified or eligible for certification by the American Board of Obstetrics and Gynecologists or the American Board of Pediatrics is required to have overall responsibility of the unit. If a physician with those qualifications is not available, a physician with training and experience in obstetrics and gynecology or pediatrics is permitted to administer the service, while a physician with the necessary qualifications provides consultation at a frequency that will assure high quality service. Requires the physician to be responsible for providing continuous obstetric, pediatric, anesthesia, laboratory, and radiologic coverage, among other requirements. Requires one registered nurse on duty on each shift assigned to the labor and delivery suite, with sufficient additional trained personnel to assist the family, monitor and evaluate labor and assist with the delivery. One registered nurse is required to be on duty for each shift assigned to the antepartum and postpartum areas, and a registered nurse who has had training and experience in neonatal nursing is required to be responsible for the nursing care in the nursery.
3. Sharp increase in maternity unit closures. On November 15, 2023, CalMatters published an investigative story focusing on the increase in maternity unit closures in California, titled “As Hospitals Close Labor Wards, Large Stretches of California Are Without Maternity Care.” According to this report, from 2012 to 2019, at least 19 hospitals stopped offering labor and delivery services (six of those were because the hospitals closed completely). In an acceleration, 16 more closed maternity services from 2020 to 2022. By the time of publication, 11 more had announced maternity closures in 2023, including one hospital that closed completely (Madera Community Hospital). CalMatters reported that after El Centro Regional Medical Center closed its maternity service in January of 2023, Imperial County was left with only one hospital doing births for the approximately 2,500 babies born every year in Imperial County. In total, according to CalMatters analysis, at least 46 California hospitals have shut down or suspended labor and delivery since 2012, and 27 of those have taken place in the last three years. Twelve rural counties do not have any hospitals delivering babies, and Latino and low-income communities have been hit hardest by losses. CalMatters noted that the closures come as the country and state contend with a maternal mortality crisis, with pregnancy-related deaths reaching a ten-year high in 2020 in California.
   
   The CalMatters report stated that hospital administrators cite a number of reasons for the closures, including high costs, labor shortages, and declining birth rates. In the past 30 years, the number of births have dropped by half in California, and the birth rate is at its lowest level on record. CalMatters noted that the trend is not unique to California, with labor and delivery units closing across the country. Many closures result from hospital systems consolidating maternity care into one location, which hospitals argue can help maintain staff training and provide a higher level of care. According to CalMatters, labor and delivery units are often the second-most expensive department for hospitals to run, second only to emergency rooms, and quoted a health researcher as stating that obstetrics units are often unprofitable for hospitals to operate.
   
4. Current process for closing an emergency department requires an impact evaluation. Under existing law, while most supplemental services only require a 90 day notice, hospitals are required to provide at least a 180 day notice prior to a planned reduction or elimination of the level of EMS to CDPH, the local health department, and all health plans or other entities under contract with the hospital to provide services to enrollees. A separate provision of law, which permits a hospital to surrender a license or permit with the approval of CDPH, specifies that “before approving a downgrade or closure of emergency services,” the county or the local EMS agency is required to conduct an impact evaluation of the downgrade or closure upon the community, and how that downgrade or closure will affect emergency services provided by other entities. This impact evaluation is required to incorporate at least one public hearing, and must be done within 60 days of CDPH receiving notice of the intent to downgrade or close emergency services. Despite the language stating “before approving a downgrade or closure of emergency services,” CDPH has not interpreted this provision of law as giving them the ability to deny a hospital the ability to close or reduce emergency services, and therefore the impact evaluation is more of a tool to help the community and the local emergency services agency prepare for the reduction or closure.

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: Yes

According to Senate Appropriations Committee, unknown, ongoing General Fund costs for HCAI, CDPH, and DHCS for state administration.

SUPPORT: (Verified 8/15/24)

American College of Obstetricians and Gynecologists District IX (co-source)

California Nurse-Midwives Association (co-source)

Reproductive Freedom for All California (co-source)

California Academy of Family Physicians

California Chapter of the American College of Emergency Physicians

California Legislative Women’s Caucus

California Medical Association

California Women’s Law Center

CleanEarth4Kids.org

Consumer Watchdog

First 5 California

Local Health Plans of California

Mee Memorial Healthcare System

Office of Lieutenant Governor Eleni Kounalakis

San Francisco Women’s Political Committee

One individual

OPPOSITION: (Verified 8/15/24)

None received

ARGUMENTS IN SUPPORT: The American College of Obstetricians and Gynecologists District IX (ACOG), one of several co-sponsors of this bill, states that the closure of maternity wards not only diminishes access to essential prenatal and postnatal care, but also poses significant risks to the health and safety of expectant mothers and their newborns. Without local access to these vital services, pregnant women are forced to travel long distances for care, which can lead to delays in receiving necessary medical attention. The California Nurse-Midwives Association (CNMA), also a co-sponsor, states that when labor and delivery units close, prenatal care providers seek to practice in geographic areas where they can attend births at a facility closer to where they also provide prenatal care, leading to not only the loss of a delivering facility, but also a decrease in prenatal care. The reporting requirements in this bill will provide much-needed data to better understand and evaluate the challenges that labor and delivery units face, and can foster targeted interventions to support the sustainability of these units. Reproductive Freedom for All California, another co-sponsor, points to a study published by the Journal of the American Medical Association that showed that rural U.S. counties not adjacent to urban areas fare the worst with the loss of hospital-based obstetric practices, and for these counties, maternity ward closures were associated with preterm birth. Reproductive Freedom for All states that there are currently no protections in place to try and prevent the closure of labor and delivery units before they occur, and that under current law the state is only notified once a decision to close has already been made. Without processes in place to understand which hospital maternity wards are at risk of closure, the state has no opportunity to intervene, or consider these facts when making policy and budget decisions.

ASSEMBLY FLOOR: 64-1, 5/21/24

AYES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Juan Carrillo, Wendy Carrillo, Chen, Connolly, Davies, Mike Fong, Garcia, Gipson, Grayson, Haney, Hart, Irwin, Jackson, Jones-Sawyer, Kalra, Lackey, Lee, Low, Lowenthal, Maienschein, McCarty, McKinnor, Muratsuchi, Stephanie Nguyen, Ortega, Pacheco, Papan, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Rendon, Reyes, Luz Rivas, Rodriguez, Blanca Rubio, Santiago, Schiavo, Soria, Ting, Valencia, Villapudua, Waldron, Wallis, Ward, Weber, Wicks, Wilson, Wood, Zbur, Robert Rivas

NOES: Essayli

NO VOTE RECORDED: Cervantes, Megan Dahle, Dixon, Flora, Vince Fong, Friedman, Gabriel, Gallagher, Holden, Hoover, Mathis, Jim Patterson, Joe Patterson, Sanchez, Ta

Prepared by: Vincent D. Marchand / HEALTH / (916) 651-4111

8/26/24 17:00:51

**** END ****

 THIRD READING  

Bill No: AB 1895

Author: Weber (D)

Amended: 6/24/24 in Senate

Vote: 21

SENATE HEALTH COMMITTEE: 9-2, 7/3/24

AYES: Roth, Glazer, Gonzalez, Hurtado, Limón, Menjivar, Rubio, Smallwood-Cuevas, Wiener

NOES: Nguyen, Grove

SENATE APPROPRIATIONS COMMITTEE: 4-2, 8/15/24

AYES: Caballero, Ashby, Becker, Wahab

NOES: Jones, Seyarto

NO VOTE RECORDED: Bradford

ASSEMBLY FLOOR: 64-1, 5/21/24 - See last page for vote

SUBJECT: Public health: maternity ward closures

SOURCE: American College of Obstetricians and Gynecologists District IX

California Nurse-Midwives Association

Reproductive Freedom for All California

DIGEST:

This bill requires a hospital that operates a perinatal unit, and expects challenges in the next six months that may result in a reduction or loss of perinatal services, to make a report to the Department of Health Care Access and Information (HCAI), and requires HCAI to forward this report to relevant state departments and to the Chairs of the Senate and Assembly Health Committees, but otherwise requires this report to be kept confidential. Requires HCAI to do a community impact assessment of a potential closure within 90 days of receiving a report from a hospital, and to share this impact assessment with state agencies and the two policy committee chairs, but otherwise requires this impact assessment to be kept confidential unless the hospital announces a closure of the perinatal services.

ANALYSIS:

Existing law:

1. Licenses and regulates health facilities by the California Department of Public Health (CDPH), including general acute care hospitals, acute psychiatric hospitals, skilled nursing facilities, and intermediate care facilities, among others. [HSC §1250, et seq.]
2. Requires any hospital that provides emergency medical services (EMS) to provide notice of a planned reduction or elimination of the level of EMS to CDPH, the local government entity in charge of the provision of health services, and all health care service plans or other entities under contract with the hospital, as soon as possible but not later than 180 days prior to the planned reduction or elimination of emergency services. Requires the hospital to also provide public notice, within the same time limits, in a manner that is likely to reach a significant number of residents of the community serviced by that facility. [HSC §1255.1]
3. Specifies that a hospital is not subject to the notice requirements in 2) above if CDPH determines that the use of resources to keep the emergency center open substantially threatens the stability of the hospital as a whole, or if CDPH cites the emergency center for unsafe staffing practices. [HSC §1255.1(c)]
4. Requires a health facility implementing a downgrade or change to make reasonable efforts to ensure that the community served by its facility is informed of the downgrade or closure, including advertising the change in terms likely to be understood by a layperson, soliciting media coverage regarding the change, informing patients of the facility of the impending change, and notifying contracting health plans. [HSC §1255.2]
5. Permits a health facility license holder, with the approval of CDPH, to surrender its license or special permit for suspension or cancellation by CDPH. Requires CDPH, before approving a downgrade or closure of emergency services, to receive a copy of an impact evaluation by the county to determine impacts of the closure or downgrade on the community. Permits the county to designate the local EMS agency as the appropriate agency to conduct the impact evaluation. Requires development of the impact evaluation to incorporate at least one public hearing, and requires the impact evaluation and hearing to be completed within 60 days of the county receiving notification of intent to downgrade or close emergency services. [HSC §1300]
6. Requires a general acute care hospital or acute psychiatric hospital, not less than 120 days prior to closing the facility, or 90 days prior to eliminating a supplemental service, or relocating a supplemental service to a different campus, to provide public notice, containing specified information, of the proposed closure, elimination, or relocation, including a notice posted at the entrance to all affected facilities and a notice to CDPH and the board of supervisors of the county in which the health facility is located. Requires the notice to include, among other items, a description of the three nearest available comparable services in the community. [HSC §1255.25]
7. Excludes county facilities from the public notice requirements of 6) above, as county facilities are subject to separate provisions of law requiring counties to provide public notice and public hearings when proposing to eliminate or reduce the level of medical services provided by a county, or when selling or transferring management of these service. This process is known as the Beilenson Act. [HSC §1442.5]
8. Establishes the Department of Health Care Access and Information (HCAI), and among other responsibilities, designates HCAI as the state agency designated to collect health facility data for use by all state agencies, including various financial data reports. [HSC §127000, et seq. and §128730]

This bill:

1. Requires a hospital that operates a perinatal unit, and expects challenges in the next six months that may result in a reduction or loss of perinatal services, to report the following information to HCAI:
   1. The number of medical staff and employees working in the perinatal unit;
   2. The number of deliveries per month over the past 12 months in the perinatal unit;
   3. The number of patients served in the perinatal unit over the past 12 months who had commercial insurance, Medi-Cal, or Medicare; and,
   4. The hospital’s prior performance on financial metrics from the past 12 months.
2. Requires HCAI to forward the hospital’s report to the Department of Health Care Services (DHCS), CDPH, and the Chairs of the Senate and Assembly Committees on Health.
3. Requires the information in the report to be kept confidential to the extent permitted by applicable law.
4. Requires a hospital, when determining whether it is expecting challenges and is required to submit the report in 1) above, and when developing the report, to consider financial challenges, difficulties finding and retaining qualified workforce members, decreased demand for perinatal services, and birth volume.
5. Requires HCAI, in conjunction with CDPH and DHCS, upon receipt of a report from a hospital under the provisions of this bill, to assess the potential impact to the community served of a closure of the hospital’s perinatal unit. Requires this community impact assessment to identify the three closest hospitals operating a perinatal unit, their distance from the challenged facility, and whether those hospitals have any restrictions on their reproductive health services.
6. Requires the community impact assessment to be completed within three months of receipt of the report from the hospital, and requires HCAI to provide the community impact assessment to the hospital, DHCS, CDPH, and the Chairs of the Senate and Assembly Committees on Health.
7. Requires the community impact assessment, notwithstanding any other law, to be kept confidential by all recipients, unless the perinatal unit is closed.
8. Requires a hospital, if it closes its perinatal unit, to provide public notice of the closure in accordance with Existing Law 6), and to include the results of the community impact assessment. Requires the notice to be posted on the hospital’s website 90 days in advance of the closure, requires the public to be permitted to comment on the closure for 60 days after the notice is given, and requires at least one noticed public hearing to be conducted by the hospital within the 60 day public comment period.
9. Prohibits a violation of this bill from serving as the basis for an administrative penalty under existing provisions of law providing for administrative assessments for violations of the laws governing licensed hospitals.

Comments

1. Author’s statement. According to the author, “last November, CalMatters published an article on the issue of maternity ward closures. In that story, they found that between 2012 and 2019, at least 19 California hospitals stopped offering labor and delivery services. Six of those hospitals closed completely. That number rose when sixteen more hospitals closed their maternity wards between 2020 to 2022. After El Centro Regional Medical Center closed its maternity ward in January, Imperial County has only one hospital left delivering babies. Under current law, the state is only notified once a decision to close a maternity unit has already been made. Without prior notification, the state has no opportunity to intervene when possible, or consider these facts when making policy and budget decisions. Alternatively, this bill requires hospitals to notify the state when their maternity unit is at risk of closure.”
2. Background on perinatal units in hospitals. With some exceptions, general acute care hospitals are required to provide eight basic services: medical, nursing, surgical, anesthesia, laboratory, radiology, pharmacy, and dietary. Beyond these basic services, hospitals can be authorized to offer supplemental services, including outpatient services such as emergency services, or inpatient services such as intensive care, cardiovascular surgery, perinatal units, and psychiatric units, among other supplemental services.
   
   Perinatal units are defined in regulations as a maternity and newborn service of the hospital for the provision of care during pregnancy, labor, delivery, postpartum, and neonatal periods with appropriate staff, space, equipment and supplies. The regulations pertaining to the required staff for perinatal units specify that a physician certified or eligible for certification by the American Board of Obstetrics and Gynecologists or the American Board of Pediatrics is required to have overall responsibility of the unit. If a physician with those qualifications is not available, a physician with training and experience in obstetrics and gynecology or pediatrics is permitted to administer the service, while a physician with the necessary qualifications provides consultation at a frequency that will assure high quality service. Requires the physician to be responsible for providing continuous obstetric, pediatric, anesthesia, laboratory, and radiologic coverage, among other requirements. Requires one registered nurse on duty on each shift assigned to the labor and delivery suite, with sufficient additional trained personnel to assist the family, monitor and evaluate labor and assist with the delivery. One registered nurse is required to be on duty for each shift assigned to the antepartum and postpartum areas, and a registered nurse who has had training and experience in neonatal nursing is required to be responsible for the nursing care in the nursery.
3. Sharp increase in maternity unit closures. On November 15, 2023, CalMatters published an investigative story focusing on the increase in maternity unit closures in California, titled “As Hospitals Close Labor Wards, Large Stretches of California Are Without Maternity Care.” According to this report, from 2012 to 2019, at least 19 hospitals stopped offering labor and delivery services (six of those were because the hospitals closed completely). In an acceleration, 16 more closed maternity services from 2020 to 2022. By the time of publication, 11 more had announced maternity closures in 2023, including one hospital that closed completely (Madera Community Hospital). CalMatters reported that after El Centro Regional Medical Center closed its maternity service in January of 2023, Imperial County was left with only one hospital doing births for the approximately 2,500 babies born every year in Imperial County. In total, according to CalMatters analysis, at least 46 California hospitals have shut down or suspended labor and delivery since 2012, and 27 of those have taken place in the last three years. Twelve rural counties do not have any hospitals delivering babies, and Latino and low-income communities have been hit hardest by losses. CalMatters noted that the closures come as the country and state contend with a maternal mortality crisis, with pregnancy-related deaths reaching a ten-year high in 2020 in California.
   
   The CalMatters report stated that hospital administrators cite a number of reasons for the closures, including high costs, labor shortages, and declining birth rates. In the past 30 years, the number of births have dropped by half in California, and the birth rate is at its lowest level on record. CalMatters noted that the trend is not unique to California, with labor and delivery units closing across the country. Many closures result from hospital systems consolidating maternity care into one location, which hospitals argue can help maintain staff training and provide a higher level of care. According to CalMatters, labor and delivery units are often the second-most expensive department for hospitals to run, second only to emergency rooms, and quoted a health researcher as stating that obstetrics units are often unprofitable for hospitals to operate.
   
4. Current process for closing an emergency department requires an impact evaluation. Under existing law, while most supplemental services only require a 90 day notice, hospitals are required to provide at least a 180 day notice prior to a planned reduction or elimination of the level of EMS to CDPH, the local health department, and all health plans or other entities under contract with the hospital to provide services to enrollees. A separate provision of law, which permits a hospital to surrender a license or permit with the approval of CDPH, specifies that “before approving a downgrade or closure of emergency services,” the county or the local EMS agency is required to conduct an impact evaluation of the downgrade or closure upon the community, and how that downgrade or closure will affect emergency services provided by other entities. This impact evaluation is required to incorporate at least one public hearing, and must be done within 60 days of CDPH receiving notice of the intent to downgrade or close emergency services. Despite the language stating “before approving a downgrade or closure of emergency services,” CDPH has not interpreted this provision of law as giving them the ability to deny a hospital the ability to close or reduce emergency services, and therefore the impact evaluation is more of a tool to help the community and the local emergency services agency prepare for the reduction or closure.

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: Yes

According to Senate Appropriations Committee, unknown, ongoing General Fund costs for HCAI, CDPH, and DHCS for state administration.

SUPPORT: (Verified 8/15/24)

American College of Obstetricians and Gynecologists District IX (co-source)

California Nurse-Midwives Association (co-source)

Reproductive Freedom for All California (co-source)

California Academy of Family Physicians

California Chapter of the American College of Emergency Physicians

California Legislative Women’s Caucus

California Medical Association

California Women’s Law Center

CleanEarth4Kids.org

Consumer Watchdog

First 5 California

Local Health Plans of California

Mee Memorial Healthcare System

Office of Lieutenant Governor Eleni Kounalakis

San Francisco Women’s Political Committee

One individual

OPPOSITION: (Verified 8/15/24)

None received

ARGUMENTS IN SUPPORT: The American College of Obstetricians and Gynecologists District IX (ACOG), one of several co-sponsors of this bill, states that the closure of maternity wards not only diminishes access to essential prenatal and postnatal care, but also poses significant risks to the health and safety of expectant mothers and their newborns. Without local access to these vital services, pregnant women are forced to travel long distances for care, which can lead to delays in receiving necessary medical attention. The California Nurse-Midwives Association (CNMA), also a co-sponsor, states that when labor and delivery units close, prenatal care providers seek to practice in geographic areas where they can attend births at a facility closer to where they also provide prenatal care, leading to not only the loss of a delivering facility, but also a decrease in prenatal care. The reporting requirements in this bill will provide much-needed data to better understand and evaluate the challenges that labor and delivery units face, and can foster targeted interventions to support the sustainability of these units. Reproductive Freedom for All California, another co-sponsor, points to a study published by the Journal of the American Medical Association that showed that rural U.S. counties not adjacent to urban areas fare the worst with the loss of hospital-based obstetric practices, and for these counties, maternity ward closures were associated with preterm birth. Reproductive Freedom for All states that there are currently no protections in place to try and prevent the closure of labor and delivery units before they occur, and that under current law the state is only notified once a decision to close has already been made. Without processes in place to understand which hospital maternity wards are at risk of closure, the state has no opportunity to intervene, or consider these facts when making policy and budget decisions.

ASSEMBLY FLOOR: 64-1, 5/21/24

AYES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Juan Carrillo, Wendy Carrillo, Chen, Connolly, Davies, Mike Fong, Garcia, Gipson, Grayson, Haney, Hart, Irwin, Jackson, Jones-Sawyer, Kalra, Lackey, Lee, Low, Lowenthal, Maienschein, McCarty, McKinnor, Muratsuchi, Stephanie Nguyen, Ortega, Pacheco, Papan, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Rendon, Reyes, Luz Rivas, Rodriguez, Blanca Rubio, Santiago, Schiavo, Soria, Ting, Valencia, Villapudua, Waldron, Wallis, Ward, Weber, Wicks, Wilson, Wood, Zbur, Robert Rivas

NOES: Essayli

NO VOTE RECORDED: Cervantes, Megan Dahle, Dixon, Flora, Vince Fong, Friedman, Gabriel, Gallagher, Holden, Hoover, Mathis, Jim Patterson, Joe Patterson, Sanchez, Ta

Prepared by: Vincent D. Marchand / HEALTH / (916) 651-4111

8/18/24 8:51:10

**** END ****

SENATE COMMITTEE ON APPROPRIATIONS

Senator Anna Caballero, Chair

2023 - 2024 Regular Session

AB 1895 (Weber) - Public health: maternity ward closures

Bill Summary:

AB 1895 would impose requirements on a hospital that operates a perinatal unit and expects challenges that may result in a reduction or loss of perinatal services, as specified.

Fiscal Impact:

Unknown, ongoing General Fund costs for the Department of Health Care Access and Information (HCAI), the California Department of Public Health (CDPH), and the Department of Health Care Services (DHCS) for state administration.

Background:

The CDPH licenses and regulates health facilities, including general acute care hospitals, acute psychiatric hospitals, skilled nursing facilities, and intermediate care facilities, among others. With some exceptions, general acute care hospitals are required to provide eight basic services: medical, nursing, surgical, anesthesia, laboratory, radiology, pharmacy, and dietary. Beyond these basic services, hospitals can be authorized to offer supplemental services, including outpatient services such as emergency services, or inpatient services such as intensive care, cardiovascular surgery, maternity, and a psychiatric unit, among other supplemental services.

Current law requires a general acute care hospital or acute psychiatric hospital, not less than 120 days prior to closing the facility, or 90 days prior to eliminating a supplemental service (such as maternity), or relocating a supplemental service to a different campus, to provide public notice, containing specified information, of the proposed closure, elimination, or relocation.

Perinatal units are defined in regulations as a maternity and newborn service of the hospital for the provision of care during pregnancy, labor, delivery, postpartum, and neonatal periods with appropriate staff, space, equipment and supplies. Regulations also specify the staffing necessary for perinatal units.

Proposed Law:

Specific provisions of the bill would:

• Require that if a hospital that operates a perinatal unit expects challenges in the next six months that may result in a reduction or loss of perinatal services as determined by the hospital after considering factors, as described, the hospital must report information, as specified, to the HCAI.
• Require HCAI, in conjunction with the CDPH and the DHCS, to assess the potential impact to the community served of a closure of the hospital’s perinatal unit, as specified; require the community impact assessment to be completed within three months of receipt of the report from the hospital; require HCAI to provide the community impact assessment to the hospital, the DHCS, the CDPH, the Chair of the Senate Committee on Health, and the Chair of the Assembly Committee on Health; and require the community impact assessment to be kept confidential by all recipients.
• Require that if the hospital closes its perinatal unit, the hospital must provide public notice of the closure in accordance with existing law and must include the results of the community impact assessment; require the public notice to be posted on the hospital’s internet website 90 days in advance of the closure; and require that the public be permitted to comment on the closure for 60 days after the notice is given, with at least one noticed public hearing conducted by the hospital.

Related Legislation:

SB 1300 (Cortese) would require additional reporting and notice requirements for health facilities related to the closure of either inpatient psychiatric services or maternity services. The bill is currently on the Assembly floor.

-- END --

SENATE COMMITTEE ON HEALTH

Senator Richard Roth, Chair

BILL NO: AB 1895

SUBJECT: Public health: maternity ward closures

SUMMARY:

Requires a hospital that operates a perinatal unit, and expects challenges in the next six months that may result in a reduction or loss of perinatal services, to make a report to the Department of Health Care Access and Information (HCAI), and requires HCAI to forward this report to relevant state departments and to the Chairs of the Senate and Assembly Health Committees, but otherwise requires this report to be kept confidential. Requires HCAI to do a community impact assessment of a potential closure within 90 days of receiving a report from a hospital, and to share this impact assessment with state agencies and the two policy committee chairs, but otherwise requires this impact assessment to be kept confidential unless the hospital announces a closure of the perinatal services.

Existing law:

1. Licenses and regulates health facilities by the California Department of Public Health (CDPH), including general acute care hospitals, acute psychiatric hospitals, skilled nursing facilities, and intermediate care facilities, among others. [HSC §1250, et seq.]
2. Requires any hospital that provides emergency medical services (EMS) to provide notice of a planned reduction or elimination of the level of EMS to CDPH, the local government entity in charge of the provision of health services, and all health care service plans or other entities under contract with the hospital, as soon as possible but not later than 180 days prior to the planned reduction or elimination of emergency services. Requires the hospital to also provide public notice, within the same time limits, in a manner that is likely to reach a significant number of residents of the community serviced by that facility. [HSC §1255.1]
3. Specifies that a hospital is not subject to the notice requirements in 2) above if CDPH determines that the use of resources to keep the emergency center open substantially threatens the stability of the hospital as a whole, or if CDPH cites the emergency center for unsafe staffing practices. [HSC §1255.1(c)]
4. Requires a health facility implementing a downgrade or change to make reasonable efforts to ensure that the community served by its facility is informed of the downgrade or closure, including advertising the change in terms likely to be understood by a layperson, soliciting media coverage regarding the change, informing patients of the facility of the impending change, and notifying contracting health plans. [HSC §1255.2]
5. Permits a health facility license holder, with the approval of CDPH, to surrender its license or special permit for suspension or cancellation by CDPH. Requires CDPH, before approving a downgrade or closure of emergency services, to receive a copy of an impact evaluation by the county to determine impacts of the closure or downgrade on the community. Permits the county to designate the local EMS agency as the appropriate agency to conduct the impact evaluation. Requires development of the impact evaluation to incorporate at least one public hearing, and requires the impact evaluation and hearing to be completed within 60 days of the county receiving notification of intent to downgrade or close emergency services.

[HSC §1300]

1. Requires a general acute care hospital or acute psychiatric hospital, not less than 120 days prior to closing the facility, or 90 days prior to eliminating a supplemental service, or relocating a supplemental service to a different campus, to provide public notice, containing specified information, of the proposed closure, elimination, or relocation, including a notice posted at the entrance to all affected facilities and a notice to CDPH and the board of supervisors of the county in which the health facility is located. Requires the notice to include, among other items, a description of the three nearest available comparable services in the community. [HSC §1255.25]
2. Excludes county facilities from the public notice requirements of 6) above, as county facilities are subject to separate provisions of law requiring counties to provide public notice and public hearings when proposing to eliminate or reduce the level of medical services provided by a county, or when selling or transferring management of these service. This process is known as the Beilenson Act. [HSC §1442.5]
3. Establishes the Department of Health Care Access and Information (HCAI), and among other responsibilities, designates HCAI as the state agency designated to collect health facility data for use by all state agencies, including various financial data reports. [HSC §127000, et seq. and §128730]

This bill:

1. Requires a hospital that operates a perinatal unit, and expects challenges in the next six months that may result in a reduction or loss of perinatal services, to report the following information to HCAI:
   1. The number of medical staff and employees working in the perinatal unit;
   2. The number of deliveries per month over the past 12 months in the perinatal unit;
   3. The number of patients served in the perinatal unit over the past 12 months who had commercial insurance, Medi-Cal, or Medicare; and,
   4. The hospital’s prior performance on financial metrics from the past 12 months.
2. Requires HCAI to forward the hospital’s report to the Department of Health Care Services (DHCS), CDPH, and the Chairs of the Senate and Assembly Committees on Health.
3. Requires the information in the report to be kept confidential to the extent permitted by applicable law.
4. Requires a hospital, when determining whether it is expecting challenges and is required to submit the report in 1) above, and when developing the report, to consider financial challenges, difficulties finding and retaining qualified workforce members, decreased demand for perinatal services, and birth volume.
5. Requires HCAI, in conjunction with CDPH and DHCS, upon receipt of a report from a hospital under the provisions of this bill, to assess the potential impact to the community served of a closure of the hospital’s perinatal unit. Requires this community impact assessment to identify the three closest hospitals operating a perinatal unit, their distance from the challenged facility, and whether those hospitals have any restrictions on their reproductive health services.
6. Requires the community impact assessment to be completed within three months of receipt of the report from the hospital, and requires HCAI to provide the community impact assessment to the hospital, DHCS, CDPH, and the Chairs of the Senate and Assembly Committees on Health.
7. Requires the community impact assessment, notwithstanding any other law, to be kept confidential by all recipients, unless the perinatal unit is closed.
8. Requires a hospital, if it closes its perinatal unit, to provide public notice of the closure in accordance with Existing Law 6), and to include the results of the community impact assessment. Requires the notice to be posted on the hospital’s website 90 days in advance of the closure, requires the public to be permitted to comment on the closure for 60 days after the notice is given, and requires at least one noticed public hearing to be conducted by the hospital within the 60 day public comment period.
9. Prohibits a violation of this bill from serving as the basis for an administrative penalty under existing provisions of law providing for administrative assessments for violations of the laws governing licensed hospitals.

FISCAL EFFECT:

According to the Assembly Appropriations Committee, HCAI will need to add one staff position to promulgate regulations and conduct community impact assessments, and estimates it will need $165,000 for fiscal year (FY) 2024-25 and $171,000 for FY 2025-26 and ongoing (General Fund). CDPH estimates minor and absorbable costs to prepare community impact assessments in conjunction with HCAI that includes the locations of the three nearest hospitals offering maternity services by calculating their distance from the at-risk facility. CDPH does not anticipate any significant increases in workloads to monitor compliance with this bill's provisions during routine surveys or to investigate complaints. Unknown, but likely minor and absorbable costs to DHCS.

PRIOR VOTES:

COMMENTS:

1. Author’s statement. According to the author, last November, CalMatters published an article on the issue of maternity ward closures. In that story, they found that between 2012 and 2019, at least 19 California hospitals stopped offering labor and delivery services. Six of those hospitals closed completely. That number rose when sixteen more hospitals closed their maternity wards between 2020 to 2022. After El Centro Regional Medical Center closed its maternity ward in January, Imperial County has only one hospital left delivering babies. Under current law, the state is only notified once a decision to close a maternity unit has already been made. Without prior notification, the state has no opportunity to intervene when possible, or consider these facts when making policy and budget decisions. Alternatively, this bill requires hospitals to notify the state when their maternity unit is at risk of closure.
2. Background on perinatal units in hospitals. With some exceptions, general acute care hospitals are required to provide eight basic services: medical, nursing, surgical, anesthesia, laboratory, radiology, pharmacy, and dietary. Beyond these basic services, hospitals can be authorized to offer supplemental services, including outpatient services such as emergency services, or inpatient services such as intensive care, cardiovascular surgery, perinatal units, and psychiatric units, among other supplemental services.
   
   Perinatal units are defined in regulations as a maternity and newborn service of the hospital for the provision of care during pregnancy, labor, delivery, postpartum, and neonatal periods with appropriate staff, space, equipment and supplies. The regulations pertaining to the required staff for perinatal units specify that a physician certified or eligible for certification by the American Board of Obstetrics and Gynecologists or the American Board of Pediatrics is required to have overall responsibility of the unit. If a physician with those qualifications is not available, a physician with training and experience in obstetrics and gynecology or pediatrics is permitted to administer the service, while a physician with the necessary qualifications provides consultation at a frequency that will assure high quality service. Requires the physician to be responsible for providing continuous obstetric, pediatric, anesthesia, laboratory, and radiologic coverage, among other requirements. Requires one registered nurse on duty on each shift assigned to the labor and delivery suite, with sufficient additional trained personnel to assist the family, monitor and evaluate labor and assist with the delivery. One registered nurse is required to be on duty for each shift assigned to the antepartum and postpartum areas, and a registered nurse who has had training and experience in neonatal nursing is required to be responsible for the nursing care in the nursery.
3. Sharp increase in maternity unit closures. On November 15, 2023, CalMatters published an investigative story focusing on the increase in maternity unit closures in California, titled “As Hospitals Close Labor Wards, Large Stretches of California Are Without Maternity Care.” According to this report, from 2012 to 2019, at least 19 hospitals stopped offering labor and delivery services (six of those were because the hospitals closed completely). In an acceleration, 16 more closed maternity services from 2020 to 2022. By the time of publication, 11 more had announced maternity closures in 2023, including one hospital that closed completely (Madera Community Hospital). CalMatters reported that after El Centro Regional Medical Center closed its maternity service in January of 2023, Imperial County was left with only one hospital doing births for the approximately 2,500 babies born every year in Imperial County. In total, according to CalMatters analysis, at least 46 California hospitals have shut down or suspended labor and delivery since 2012, and 27 of those have taken place in the last three years. Twelve rural counties do not have any hospitals delivering babies, and Latino and low-income communities have been hit hardest by losses. CalMatters noted that the closures come as the country and state contend with a maternal mortality crisis, with pregnancy-related deaths reaching a ten-year high in 2020 in California.
   
   The CalMatters report stated that hospital administrators cite a number of reasons for the closures, including high costs, labor shortages, and declining birth rates. In the past 30 years, the number of births have dropped by half in California, and the birth rate is at its lowest level on record. CalMatters noted that the trend is not unique to California, with labor and delivery units closing across the country. Many closures result from hospital systems consolidating maternity care into one location, which hospitals argue can help maintain staff training and provide a higher level of care. According to CalMatters, labor and delivery units are often the second-most expensive department for hospitals to run, second only to emergency rooms, and quoted a health researcher as stating that obstetrics units are often unprofitable for hospitals to operate.
   
   As recently as February 8, 2024, Adventist Health Simi Valley announced it was closing its labor and delivery department and neonatal intensive care unit effective May 8, 2024. Adventist stated that births had declined by 25% at the hospital and it could no longer sustain the service. Adventist noted that Ventura County births dropped from 19 per 1,000 in 1990 to 10.5 per 1,000 in 2021.
   
4. Current process for closing an emergency department requires an impact evaluation. Under existing law, while most supplemental services only require a 90 day notice, hospitals are required to provide at least a 180 day notice prior to a planned reduction or elimination of the level of EMS to CDPH, the local health department, and all health plans or other entities under contract with the hospital to provide services to enrollees. A separate provision of law, which permits a hospital to surrender a license or permit with the approval of CDPH, specifies that “before approving a downgrade or closure of emergency services,” the county or the local EMS agency is required to conduct an impact evaluation of the downgrade or closure upon the community, and how that downgrade or closure will affect emergency services provided by other entities. This impact evaluation is required to incorporate at least one public hearing, and must be done within 60 days of CDPH receiving notice of the intent to downgrade or close emergency services. Despite the language stating “before approving a downgrade or closure of emergency services,” CDPH has not interpreted this provision of law as giving them the ability to deny a hospital the ability to close or reduce emergency services, and therefore the impact evaluation is more of a tool to help the community and the local emergency services agency prepare for the reduction or closure.
5. Related legislation. SB 1300 (Cortese) extends the public notice requirement when a health facility eliminates a supplemental service, currently 90 days prior to elimination of the service, to instead be 120 days when it involves the closure of either inpatient psychiatric services or maternity services. AB 1300 also requires a health facility that is eliminating an inpatient psychiatric or maternity supplemental service to complete an impact analysis report prior to providing notice of the proposed elimination of the supplemental service. SB 1300 is set for hearing on July 2, 2024 in the Assembly Appropriations Committee.
6. Prior legislation. AB 2037 (Wicks, Chapter 95, Statutes of 2020) increased the period of time when a hospital is required to provide public notice of a proposed closure or elimination of a supplemental service, from 90 days for the closure or downgrading of emergency services and 30 days for all other closures or eliminations of supplemental services, to 180 days prior to the elimination or downgrading of emergency services, 120 days prior to the closure of a hospital, and 90 days prior to the elimination of any other supplemental service.
   
   AB 1014 (O’Donnell of 2019) would have increased the period of time when a hospital is required to provide public notice of a proposed closure or elimination of a supplemental service, from 90 days for the closure or downgrading of emergency services and 30 days for all other closures or eliminations of supplemental services, to 180 days prior to the closure of a hospital or the elimination or downgrading of emergency services, and 90 days prior to the elimination of any other supplemental service. AB 1014 was vetoed by the Governor, who stated the following in his veto message: “I agree that hospital closures have vast impacts on communities. However, this bill would not change the fact that the State is not able to force a hospital to stay open when they are financially unable. I am concerned that this bill may exacerbate the financial and patient safety concerns that often lead to closures.”
   
   AB 2874 (Thurmond of 2018) would have required any hospital that provides EMS to notify the Attorney General no later than 180 days prior to a planned reduction or elimination of the level of EMS. AB 2874 failed passage on the Assembly Floor.
   
   SB 687 (Skinner of 2017) would have required a nonprofit corporation that operates a health facility that includes a licensed emergency center to obtain the consent of the Attorney General prior to a planned elimination or reduction in the level of EMS provided. SB 687 was vetoed by Governor Brown.
   
   AB 2400 (Price, Chapter 459, Statutes of 2008) requires hospitals, not less than 30 days prior to closing a general acute care or acute psychiatric hospital, eliminating a supplemental service, as defined in existing regulations, or relocating the provision of a supplemental service to a different campus, to provide notice to the public and the applicable administering state department.
7. Support. The American College of Obstetricians and Gynecologists District IX (ACOG), one of several co-sponsors of this bill, states that the closure of maternity wards not only diminishes access to essential prenatal and postnatal care, but also poses significant risks to the health and safety of expectant mothers and their newborns. Without local access to these vital services, pregnant women are forced to travel long distances for care, which can lead to delays in receiving necessary medical attention. The California Nurse-Midwives Association (CNMA), also a co-sponsor, states that when labor and delivery units close, prenatal care providers seek to practice in geographic areas where they can attend births at a facility closer to where they also provide prenatal care, leading to not only the loss of a delivering facility, but also a decrease in prenatal care. The reporting requirements in this bill will provide much-needed data to better understand and evaluate the challenges that labor and delivery units face, and can foster targeted interventions to support the sustainability of these units. Reproductive Freedom for All California, another co-sponsor, points to a study published by the Journal of the American Medical Association that showed that rural U.S. counties not adjacent to urban areas fare the worst with the loss of hospital-based obstetric practices, and for these counties, maternity ward closures were associated with preterm birth. Reproductive Freedom for All states that there are currently no protections in place to try and prevent the closure of labor and delivery units before they occur, and that under current law the state is only notified once a decision to close has already been made. Without processes in place to understand which hospital maternity wards are at risk of closure, the state has no opportunity to intervene, or consider these facts when making policy and budget decisions.
8. Policy comments.
   1. Confidentiality provisions raise concerns. This bill requires hospitals to submit a report to HCAI if they are operating a perinatal unit and are concerned that the unit is facing challenges that might lead to a closure or reduction in services in the next six months. This report is required to be sent to a couple of state departments, and the Chairs of the Senate and Assembly Health Committees. However, this report is required to be kept confidential “to the extent permitted by applicable law.” After getting one of these reports from a hospital, HCAI is required to conduct an impact assessment, and again this is sent to state departments as well as the two Health Committee chairs, and again it is required to be kept confidential, this time “notwithstanding any other law.” The confidentiality provisions are intended to address the concerns by hospitals that public disclosure that a unit is at risk of closure may become self-fulfilling as staff start looking for other jobs. However, Committee staff is unaware of other examples where a report is required to be provided to the Legislature, but kept confidential. There are practical considerations, such as whether the confidentiality requirements prevent the committee chairs from sharing the information with their staff, or with Senate or Assembly leadership. It is not clear what the committee chairs, or the Legislature as a whole, can do with the information provided if they are required to keep it confidential. The Committee may wish to consider whether the information provided should be kept confidential to the maximum extent feasible. Alternatively, rather than providing the reports or the impact assessments to the committee chairs, HCAI could be required to simply notify the chairs that HCAI has received a report or an impact assessment.
   2. Dueling impact assessments. This Committee heard and passed a related bill earlier this year, SB 1300 (Cortese), which is now pending in Assembly Appropriations Committee. Among other provisions, SB 1300 extends the notice required when a hospital is planning to eliminate maternity services or psychiatric services to 120 days prior to closure, rather than 90 days under existing law. Additionally, SB 1300 requires health facilities to complete an impact analysis prior to providing the notice of a planned elimination of these services, and requires this impact analysis to be provided alongside the notice of elimination of these services. SB 1300 does not contain any confidentiality provisions. Unlike SB 1300, the impact analysis under this bill is required to be completed by HCAI. While these two bills are not necessarily in direct conflict, meaning that theoretically hospitals can comply with both bills, there is some duplication and the timelines are not aligned. Should both bills pass and be enacted into law, here is how potential closures of maternity services would be addressed under these two bills:
      1. If a hospital is concerned about a risk of potential closure in the next six months (approximately 180 days), this needs to be reported to the state, and ultimately to the two chairs of the Senate and Assembly Health Committees, but otherwise the report needs to be kept confidential. Within 90 days of receiving this report, HCAI would be required to complete an impact analysis of a potential closure, which is also provided to the two chairs, and also kept confidential. (AB 1895)
      2. 120 days prior to closure of maternity services, hospitals would be required to provide public notice, along with an impact analysis that the hospital is required to complete. The impact analysis is a public document, and the county board of supervisors where the hospital is located is encouraged to hold a public hearing. (SB 1300)
      3. 90 days in advance of a planned closure of a maternity service, requires a hospital to include the impact analysis (completed by HCAI under this bill) as part of the required 90-day public notice requirement under existing law. Additionally, requires the public to be permitted to comment on the closure for 60 days after notice is given, and requires at least one noticed public hearing to be conducted by the hospital. (AB 1895)

SUPPORT AND OPPOSITION:

Support: American College of Obstetricians and Gynecologists District IX (co-sponsor)

California Nurse-Midwives Association (co-sponsor)
Reproductive Freedom for All California (co-sponsor)
California Academy of Family Physicians

California Chapter of the American College of Emergency Physicians

California Legislative Women’s Caucus

California Medical Association

California Women’s Law Center

CleanEarth4Kids.org

Consumer Watchdog

First 5 California

Local Health Plans of California

Mee Memorial Healthcare System

Office of Lieutenant Governor Eleni Kounalakis

San Francisco Women’s Political Committee

One individual

Oppose: None received

-- END --

ASSEMBLY THIRD READING

ATR Bill Id:AB 1895

Author:(Weber)

As Amended Ver:May 16, 2024

Majority vote

SUMMARY

Requires a general acute care hospital (GACH) that provides maternity services and determines those services are at risk of closing in the next six months to report specified information to the State Department of Health Care Services, the Department of Health Care Access and Information (HCAI), the State Department of Public Health (DPH), and the Chairs of the Senate and Assembly Committees on Health

Major Provisions

COMMENTS

1. Supplemental Services. With some exceptions, GACHs are required to provide eight basic services: medical, nursing, surgical, anesthesia, laboratory, radiology, pharmacy, and dietary. Beyond these basic services, hospitals can be authorized to offer supplemental services, including outpatient services such as emergency services, or inpatient services such as intensive care, cardiovascular surgery, maternity, and a psychiatric unit, among others.
2. Increasing Maternity Unit Closures. On November 15, 2023, CalMatters published an investigative story focusing on the increase in maternity unit closures in California, titled "As Hospitals Close Labor Wards, Large Stretches of California Are Without Maternity Care." According to this report, from 2012 to 2019, at least 19 hospitals stopped offering labor and delivery services (six of those were because the hospitals closed completely). In an acceleration, 16 more closed maternity services from 2020 to 2022. By the time of publication, 11 more had announced maternity closures in 2023, including one hospital that completely closed (Madera Community Hospital). CalMatters reported that after El Centro Regional Medical Center closed its maternity service in January of 2023, Imperial County was left with only one hospital doing births for the approximately 2,500 babies born every year in Imperial County. In total, according to the CalMatters analysis, at least 46 California hospitals have shut down or suspended labor and delivery since 2012, and 27 of those have taken place in the last three years. Twelve rural counties do not have any hospitals delivering babies, and Latino and low-income communities have been hit hardest by losses. CalMatters noted that the closures come as the country and state contend with a maternal mortality crisis, with pregnancy-related deaths reaching a ten-year high in 2020 in California.

The CalMatters report stated that hospital administrators cite a number of reasons for the closures, including high costs, labor shortages, and declining birth rates. In the past 30 years, the number of births have dropped by half in California, and the birth rate is at its lowest level on record. CalMatters noted that the trend is not unique to California, with labor and delivery units closing across the country. Many closures result from hospital systems consolidating maternity care into one location, which hospitals argue can help maintain staff training and provide a higher level of care. According to CalMatters, labor and delivery units are often the second-most expensive department for hospitals to run, second only to emergency rooms, and quoted a health researcher as stating that obstetrics units are often unprofitable for hospitals to operate.

As recently as February 8, 2024, Adventist Health Simi Valley announced it was closing its labor and delivery department and neonatal intensive care unit effective May 8, 2024. Adventist stated that births had declined by 25% at the hospital and it could no longer sustain the service. Adventist noted that Ventura County births dropped from 19 per 1,000 in 1990 to 10.5 per 1,000 in 2021.

1. Effects of Maternity Ward Closures. A 2018 study published by the Journal of the American Medical Association showed that rural counties not adjacent to urban areas fare the worst with the loss of hospital-based obstetric services. For these counties, maternity ward closures were associated with increases in out-of-hospital and preterm births and births in hospitals without obstetric units in the following year. The latter "emergency births" in unprepared facilities also occurred in urban-adjacent counties. The Association of State and Territorial Health Organizations notes that the effect of hospital closures goes well beyond isolated negative health consequences, including the exacerbation of poor socioeconomic conditions, job loss, transportation barriers, and overall higher health care costs for disadvantaged communities. A study set for publication in April 2024 shows that obstetric closures have a nuanced impact on communities, depending on the size and rurality of the community. For example, in far northern counties, birthing people take the understood risk of giving birth while making the long drive to their obstetric facility. Others, in more urban communities may face other negative impacts not otherwise revealed without a specific impact assessment.
2. Current Process for Closing an Emergency Department Requires an Impact Evaluation. Under existing law, while most supplemental services only require a 90 day notice, hospitals are required to provide at least a 180 day notice prior to a planned reduction or elimination of the level of emergency medical services to DPH, the local health department, and all health plans or other entities under contract with the hospital to provide services to enrollees. A separate provision of law, which permits a hospital to surrender a license or permit with the approval of DPH, specifies that "before approving a downgrade or closure of emergency services," the county or the local emergency medical services agency is required to conduct an impact evaluation of the downgrade or closure upon the community, and how that downgrade or closure will affect emergency services provided by other entities. This impact evaluation is required to incorporate at least one public hearing, and must be done within 60 days of DPH receiving notice of the intent to downgrade or close emergency services. Despite the language stating "before approving a downgrade or closure of emergency services," DPH has not interpreted this provision of law as giving them the ability to deny a hospital the ability to close or reduce emergency services, and therefore the impact evaluation is more of a tool to help the community and the local emergency services agency prepare for the reduction or closure.

This bill would implement a similar process, requiring HCAI, in conjunction with DPH, to conduct a community impact assessment regarding the closure of a maternity ward. The author has requested $1.5 million from the General Fund for the staffing and administration of this bill.

According to the Author

Last November, CalMatters published an article on the issue of maternity ward closures. In that story, they found that between 2012 and 2019, at least 19 California hospitals stopped offering labor and delivery services. Six of those hospitals closed completely. That number rose when sixteen more hospitals closed their maternity wards between 2020 and 2022. Under current law, the state is only notified once a decision to close a maternity unit has already been made. Without prior notification, the state has no opportunity to intervene when possible, or consider these facts when making policy and budget decisions.

Arguments in Support

American College of Obstetricians and Gynecologists, Black Women for Wellness Action Project, California Nurse Midwives Association, and Reproductive Freedom for All California are the cosponsors of this bill. The cosponsors note that GACHs that offer basic and specialty maternity services provide needed obstetric care for most women who are giving birth in California, as well as the rest of the United States. They often provide maternity care in rural and underserved communities, which offers the benefit of keeping women with low- or moderate-risk pregnancies in their local communities. The closure of maternity wards not only diminishes access to essential prenatal and postnatal care but also poses significant risks to the health and safety of expectant mothers and their newborns. Without local access to these vital services, pregnant women are forced to travel long distances for care, which can lead to delays in receiving necessary medical attention. This is particularly concerning in cases of high-risk pregnancies or emergency situations where every moment is crucial. Moreover, the closure of labor and delivery units can exacerbate health disparities, especially in rural and underserved communities. These areas already face significant obstacles in accessing health care services, and the loss of local maternity wards further increases the risk of adverse birth outcomes, including preterm births and low birth weight. The ripple effects of such closures extend beyond immediate health concerns, impacting the overall well-being and socioeconomic stability of communities. The cosponsors conclude that requiring facilities to report on the number of births, staffing levels, and fiscal condition will provide valuable data to better understand the challenges the labor and delivery units face and will enable targeted interventions to support the sustainability of labor and delivery units and ensure that every family has access to safe, quality maternal care.

Arguments in Opposition

There is no known opposition to this bill.

FISCAL COMMENTS

According to the Assembly Appropriations Committee, HCAI will need to add one staff position to promulgate regulations and conduct community impact assessments, and estimates it will need $165,000 for fiscal year (FY) 2024-25 and $171,000 for FY 2025-26 and ongoing (General Fund).

DPH estimates minor and absorbable costs to prepare community impact assessments in conjunction with HCAI that includes the locations of the three nearest GACHs offering maternity services by calculating their distance from the at-risk facility. DPH does not anticipate any significant increases in workloads to monitor compliance with this bill's provisions during routine surveys or to investigate complaints.

Unknown, but likely minor and absorbable costs to DHCS.

According to the Legislative Analyst's Office, the General Fund faces a structural deficit in the tens of billions of dollars over the next several fiscal years.

VOTES

ASM HEALTH: 13-1-2

YES: Bonta, Waldron, Aguiar-Curry, Arambula, Wendy Carrillo, Haney, Jones-Sawyer, Maienschein, McCarty, Rodriguez, Santiago, Schiavo, Weber

NO: Sanchez

ABS, ABST OR NV: Flora, Joe Patterson

ASM APPROPRIATIONS: 11-3-1

YES: Wicks, Arambula, Bryan, Calderon, Wendy Carrillo, Mike Fong, Grayson, Haney, Hart, Pellerin, Villapudua

NO: Sanchez, Dixon, Ta

ABS, ABST OR NV: Jim Patterson

UPDATED

VERSION: May 16, 2024

CONSULTANT: Lara Flynn / HEALTH / (916) 319-2097 FN: 0003316

Date of Hearing: May 1, 2024

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Buffy Wicks, Chair

ABPCA Bill Id:AB 1895

Author:(Weber) – As Amended Ver:March 18, 2024

Urgency: No State Mandated Local Program: Yes Reimbursable: No

SUMMARY:

This bill requires a hospital, if it determines its maternity services are at risk of closure within 12 months, to report specified information to the Department of Health Care Access and Information (HCAI), Department of Public Health (DPH), Department of Health Care Services (DHCS), and the Senate and Assembly committees on health. This bill also requires HCAI, in conjunction with DPH, to conduct a community impact assessment regarding the closure, and requires the hospital to report the impact assessment to the public, along with notice of the potential closure, and hold a hearing.

This bill requires the hospital’s report to DHCS, HCAI, DPH, and the Legislature to include the following:

1. The number of medical staff and employees working in the maternity ward.
   
2. The number of deliveries per month over the past 12 months at the maternity ward.
3. The number of patients served over the past 12 months who have commercial insurance.
   
4. The number of patients served over the past 12 months who had Medi-Cal or Medicare.
   
5. The hospital’s prior and projected performance on financial metrics from the past 12 months.

FISCAL EFFECT:

HCAI will need to add one staff position to promulgate regulations and conduct community impact assessments, and estimates it will need $165,000 for fiscal year (FY) 2024-25 and $171,000 for FY 2025-26 and ongoing (General Fund).

DPH estimates minor and absorbable costs to prepare community impact assessments in conjunction with HCAI that includes the locations of the three nearest GACHs offering maternity services by calculating their distance from the at-risk facility. CDPH does not anticipate any significant increases in workloads to monitor compliance with this bill’s provisions during routine surveys or to investigate complaints.

Unknown, but likely minor and absorbable costs to DHCS.

According to the Legislative Analyst’s Office, the General Fund faces a structural deficit in the tens of billions of dollars over the next several fiscal years. 

COMMENTS:

1. Purpose. This bill is sponsored by the American College of Obstetricians and Gynecologists, Black Women for Wellness Action Project, California Nurse Midwives Association, and Reproductive Freedom for All California. According to the author:

Last November, CalMatters published an article on the issue of maternity ward closures. In that story, they found that between 2012 and 2019, at least 19 California hospitals stopped offering labor and delivery services. Six of those hospitals closed completely. That number rose when sixteen more hospitals closed their maternity wards between 2020 to 2022. After El Centro Regional Medical Center closed its maternity ward in January, Imperial County has only one hospital left delivering babies.

1. Concerns. The California Hospital Association (CHA) states it supports transparency and understands the desire for earlier notification on Labor and Delivery (L&D) closures. However, hospitals already provide a 90-day public notification and a 90-day notification to DPH when closing or reducing a service. CHA is concerned notification of potential closures would exacerbate the existing challenges as health care providers and staff leave their jobs after learning that a facility is at risk of closure and prospective patients would be dissuaded from seeking care at a facility that may close, resulting in diminished patient volume. CHA contends hospitals typically do not know 12 months in advance that they may need to close an L&D unit, and there are many factors hospitals must consider when making this difficult decision; however, it is often an unforeseen circumstance that ultimately pushes the hospital to decide to close its L&D unit. Finally, CHA states most of the data that hospitals would be required to report is data that they already report to HCAI on an annual or quarterly basis and is publicly available.
2. Related Legislation. SB 1300 (Cortese) extends, from 90 days to 120 days, the public notice requirement when a health facility eliminates either inpatient psychiatric services or maternity services. SB 1300 requires the facility complete an impact analysis report prior to providing notice of the proposed elimination of the supplemental service, and requires HCAI to prepare a form for this report and review and certify the impact analyses. SB 1300 is pending on the Senate floor.
3. Prior Legislation.
   1. AB 2037 (Wicks), Chapter 95, Statutes of 2020, increases the period of time a hospital is required to provide public notice of a proposed closure or elimination of a supplemental service, from 90 days for the closure or downgrading of emergency services and 30 days for all other closures or eliminations, to 180 days prior to the elimination or downgrading of emergency services, 120 days prior to the closure of a hospital, and 90 days prior to the elimination of any other supplemental service.
   2. AB 1014 (O’Donnell), of the 2019-20 Legislative Session, would have increased the period of time a hospital is required to provide public notice of a proposed closure or elimination of a supplemental service, from 90 days for emergency services and 30 days for all other services, to 180 days prior to closure of a hospital or the elimination or downgrading of emergency services, and 90 days prior to the elimination of any other supplemental service. AB 1014 was vetoed by the Governor, who stated in his veto message, “this bill would not change the fact that the State is not able to force a hospital to stay open when they are financially unable. I am concerned that this bill may exacerbate the financial and patient safety concerns that often lead to closures.”
   3. AB 2874 (Thurmond), of the 2017-18 Legislative Session, would have required any hospital that provides emergency medical services (EMS) to notify the Attorney General (AG) no later than 180 days prior to a planned reduction or elimination of the level of EMS. AB 2874 failed passage on the Assembly Floor.
      
   4. SB 687 (Skinner), of the 2017-18 Legislative Session, would have required a nonprofit corporation that operates a health facility that includes a licensed emergency center to obtain the consent of the AG prior to a planned elimination or reduction in the level of EMS provided. SB 687 was vetoed by Governor Brown, who stated:

A hospital's decision to reduce or eliminate emergency services poses real challenges for a community. This is why current law requires public notice prior to a hospital taking such an action. Removing a hospital's authority to determine emergency service needs, however, will not solve the underlying financial issues that typically force these decisions. An Attorney General decision to prohibit a reduction or elimination of these services may hasten the reduction of other services or closure of the entire hospital.

Analysis Prepared by: Allegra Kim / APPR. / (916) 319-2081

Date of Hearing: April 16, 2024

ASSEMBLY COMMITTEE ON HEALTH

Mia Bonta, Chair

ABPCA Bill Id:AB 1895

Author:(Weber) – As Amended Ver:March 18, 2024

SUBJECT: Public health: maternity ward closures.

SUMMARY: Requires a general acute care hospital (GACH) that provides maternity services and determines those services are at risk of closing in the next 12 months to report specified information to the State Department of Health Care Services (DHCS), the Department of Health Care Access and Information (HCAI), the State Department of Public Health (DPH), and the Chairs of the Senate and Assembly Committees on Health. Specifically, this bill:

1. Requires a GACH that offers the supplemental service of maternity services that determines those services are at risk of closure in the next 12 months, as determined by the hospital pursuant to the factors described in 3) below, to report the following information to DHCS, HCAI, DPH, the Chairs of the Senate and Assembly Committees on Health:
   1. The number of medical staff and employees working in the maternity ward;
   2. The number of deliveries per month over the past 12 months at the maternity ward;
   3. The number of patients served over the past 12 months who have commercial insurance;
   4. The number of patients served over the past 12 months who had Medi-Cal or Medicare; and,
   5. The hospital’s prior and projected performance on financial metrics from the past 12 months.
2. Requires the information provided pursuant to 1) above to be kept confidential to the extent permitted by applicable law.
   
3. Requires a GACH, when assessing the risk of closure of maternity services, to consider factors, including, but not limited to, financial distress, workforce shortages, decreased demand in services, and birthing volume.
   
4. Requires HCAI, in conjunction with DPH, to conduct a community impact assessment regarding the closure. Requires the community impact assessment to determine the three closest hospitals offering maternity services in the geographic area, and their distance from the at-risk facility. Requires the community impact assessment to be completed within six months of notice from the hospital that the maternity services are at risk of closure. Requires the community impact assessment to be provided to the public with the public notice described in 5) below.
   
5. Requires, if the maternity services of a GACH are at risk of closure, the GACH to provide public notice of the potential closure, including the results of the community impact assessment described in 4) above, and the information required in 6) of existing law below. Requires the public notice to be posted on the GACH’s internet website 90 days in advance of the proposed closure. Requires the public to be permitted to comment on the potential closure for 60 days after the notice is given, and within this period at least one noticed public hearing shall be conducted by the GACH, and for the GACH to also accept written public comment.

EXISTING LAW:

1. Licenses and regulates hospitals, including GACHs, DPH. Permits GACHs, in addition to the basic services all hospitals are required to offer (medical, nursing, surgical, anesthesia, laboratory, radiology, pharmacy, and dietary services), to be approved by DPH to offer special services, including, among other services, an emergency department (ED) and maternity services. [Health and Safety Code [HSC] §1250 and §1255, et seq.]
2. Requires EDs, under the federal Emergency Medical Treatment and Active Labor Act (EMTALA) and also under similar provisions of state law (state EMTALA), to provide emergency screening and stabilization services without regard to the patient’s insurance status or ability to pay. Federal EMTALA imposes this requirement on any hospital that participates in Medicare. State EMTALA imposes this requirement on any hospital that operates an ED. [42 United States Code §1395dd; HSC §1317]
   
3. Requires any hospital that provides emergency medical services (EMS) to provide notice of a planned reduction or elimination of the level of EMS to DPH, the local government entity in charge of the provision of health services, and all health care service plans or other entities under contract with the hospital, as soon as possible but not later than 180 days prior to the planned reduction or elimination of emergency services. Requires the hospital to also provide public notice, within the same time limits, in a manner that is likely to reach a significant number of residents of the community serviced by that facility. [HSC §1255.1]
4. Specifies that a hospital is not subject to the notice requirements in 3) above if DPH determines that the use of resources to keep the emergency center open substantially threatens the stability of the hospital as a whole, or if DPH cites the emergency center for unsafe staffing practices. [HSC §1255.1(c)]
5. Requires a health facility implementing a downgrade or change to make reasonable efforts to ensure that the community served by its facility is informed of the downgrade or closure, including advertising the change in terms likely to be understood by a layperson, soliciting media coverage regarding the change, informing patients of the facility of the impending change, and notifying contracting health plans. [HSC §1255.2]
   
6. Requires a health facility providing public notice of the proposed closure or elimination of a supplemental service to include the following information:
   1. A description of the proposed closure, elimination, or relocation. Requires the description to be limited to publicly available data, including the number of beds eliminated, if any, the probable decrease in the number of personnel, and a summary of any service that is being eliminated, if applicable;
   2. A description of the three nearest available comparable services in the community. Requires, if the health facility closing these services serves Medi-Cal or Medicare patients, this health facility to specify if the providers of the nearest available comparable services serve these patients;
   3. A telephone number and address for each of the following, where interested parties may offer comments:
      1. The health facility;
      2. The parent entity, if any, or contracted company, if any, that acts as the corporate administrator of the health facility; and,
      3. The chief executive officer. [HSC §1255.25]
         
7. Permits a health facility license holder, with the approval of DPH, to surrender its license or special permit for supplemental service for suspension or cancellation by DPH. Requires DPH, before approving a downgrade or closure of emergency services, to receive a copy of an impact evaluation by the county to determine impacts of the closure or downgrade on the community. Permits the county to designate the local EMS agency (LEMSA) as the appropriate agency to conduct the impact evaluation. Requires development of the impact evaluation to incorporate at least one public hearing, and requires the impact evaluation and hearing to be completed within 60 days of the county receiving notification of intent to downgrade or close emergency services.

[HSC §1300]

1. Requires a GACH, not less than 120 days prior to closing the facility, or 90 days prior to eliminating a supplemental service, or relocating a supplemental service to a different campus, to provide public notice, containing specified information, of the proposed closure, elimination, or relocation, including a notice posted at the entrance to all affected facilities and a notice to DPH and the board of supervisors of the county in which the health facility is located. [HSC §1255.25]
   
2. Excludes county facilities from the public notice requirements of 7) above, as county facilities are subject to separate provisions of law requiring counties to provide public notice and public hearings when proposing to eliminate or reduce the level of medical services provided by a county, or when selling or transferring management of these service. This process is known as the Beilenson Act. [HSC §1442.5]
   
3. Establishes HCAI in the California Health and Human Services Agency to expand equitable access to quality, affordable health care for all Californians through resilient facilities, actionable information,  and the health workforce each community needs. [HSC §127000, et seq.]
   
4. Defines supplemental service to mean an organized inpatient or outpatient service which is not required to be provided by law or regulation. [Section 70067, Article 1, Chapter 1, Division 5, Title 22 of the California Code of Regulations]
   

FISCAL EFFECT: Unknown. This bill has not yet been analyzed by a fiscal Committee.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, last November, CalMatters published an article on the issue of maternity ward closures. In that story, they found that between 2012 and 2019, at least 19 California hospitals stopped offering labor and delivery services. Six of those hospitals closed completely. That number rose when sixteen more hospitals closed their maternity wards between 2020 and 2022. Under current law, the state is only notified once a decision to close a maternity unit has already been made. Without prior notification, the state has no opportunity to intervene when possible, or consider these facts when making policy and budget decisions.
2. BACKGROUND.
   1. Supplemental Services. With some exceptions, GACHs are required to provide eight basic services: medical, nursing, surgical, anesthesia, laboratory, radiology, pharmacy, and dietary. Beyond these basic services, hospitals can be authorized to offer supplemental services, including outpatient services such as emergency services, or inpatient services such as intensive care, cardiovascular surgery, maternity, and a psychiatric unit, among others.
   2. Increasing Maternity Unit Closures. On November 15, 2023, CalMatters published an investigative story focusing on the increase in maternity unit closures in California, titled “As Hospitals Close Labor Wards, Large Stretches of California Are Without Maternity Care.” According to this report, from 2012 to 2019, at least 19 hospitals stopped offering labor and delivery services (six of those were because the hospitals closed completely). In an acceleration, 16 more closed maternity services from 2020 to 2022. By the time of publication, 11 more had announced maternity closures in 2023, including one hospital that completely closed (Madera Community Hospital). CalMatters reported that after El Centro Regional Medical Center closed its maternity service in January of 2023, Imperial County was left with only one hospital doing births for the approximately 2,500 babies born every year in Imperial County. In total, according to the CalMatters analysis, at least 46 California hospitals have shut down or suspended labor and delivery since 2012, and 27 of those have taken place in the last three years. Twelve rural counties do not have any hospitals delivering babies, and Latino and low-income communities have been hit hardest by losses. CalMatters noted that the closures come as the country and state contend with a maternal mortality crisis, with pregnancy-related deaths reaching a ten-year high in 2020 in California.
      
      The CalMatters report stated that hospital administrators cite a number of reasons for the closures, including high costs, labor shortages, and declining birth rates. In the past 30 years, the number of births have dropped by half in California, and the birth rate is at its lowest level on record. CalMatters noted that the trend is not unique to California, with labor and delivery units closing across the country. Many closures result from hospital systems consolidating maternity care into one location, which hospitals argue can help maintain staff training and provide a higher level of care. According to CalMatters, labor and delivery units are often the second-most expensive department for hospitals to run, second only to emergency rooms, and quoted a health researcher as stating that obstetrics units are often unprofitable for hospitals to operate.
      
      As recently as February 8, 2024, Adventist Health Simi Valley announced it was closing its labor and delivery department and neonatal intensive care unit effective May 8, 2024. Adventist stated that births had declined by 25% at the hospital and it could no longer sustain the service. Adventist noted that Ventura County births dropped from 19 per 1,000 in 1990 to 10.5 per 1,000 in 2021.
   3. Effects of Maternity Ward Closures. A 2018 study published by the Journal of the American Medical Association showed that rural counties not adjacent to urban areas fare the worst with the loss of hospital-based obstetric services. For these counties, maternity ward closures were associated with increases in out-of-hospital and preterm births and births in hospitals without obstetric units in the following year. The latter “emergency births” in unprepared facilities also occurred in urban-adjacent counties. The Association of State and Territorial Health Organizations notes that the effect of hospital closures goes well beyond isolated negative health consequences, including the exacerbation of poor socioeconomic conditions, job loss, transportation barriers, and overall higher health care costs for disadvantaged communities. A study set for publication in April 2024 shows that obstetric closures have a nuanced impact on communities, depending on the size and rurality of the community. For example, in far northern counties, birthing people take the understood risk of giving birth while making the long drive to their obstetric facility. Others, in more urban communities may face other negative impacts not otherwise revealed without a specific impact assessment. 
      
   4. Current Process for Closing an ED Requires an Impact Evaluation. Under existing law, while most supplemental services only require a 90 day notice, hospitals are required to provide at least a 180 day notice prior to a planned reduction or elimination of the level of EMS to DPH, the local health department, and all health plans or other entities under contract with the hospital to provide services to enrollees. A separate provision of law, which permits a hospital to surrender a license or permit with the approval of DPH, specifies that “before approving a downgrade or closure of emergency services,” the county or the LEMSA is required to conduct an impact evaluation of the downgrade or closure upon the community, and how that downgrade or closure will affect emergency services provided by other entities. This impact evaluation is required to incorporate at least one public hearing, and must be done within 60 days of DPH receiving notice of the intent to downgrade or close emergency services. Despite the language stating “before approving a downgrade or closure of emergency services,” DPH has not interpreted this provision of law as giving them the ability to deny a hospital the ability to close or reduce emergency services, and therefore the impact evaluation is more of a tool to help the community and the local emergency services agency prepare for the reduction or closure.
      
      This bill would implement a similar process, requiring HCAI, in conjunction with DPH, to conduct a community impact assessment regarding the closure of a maternity ward. The author has requested $1.5 million from the General Fund for the staffing and administration of this bill.
3. SUPPORT. American College of Obstetricians and Gynecologists (ACOG), Black Women for Wellness Action Project, California Nurse Midwives Association, and Reproductive Freedom for All California are the cosponsors of this bill. The cosponsors note that GACHs that offer basic and specialty maternity services provide needed obstetric care for most women who are giving birth in California, as well as the rest of the United States. They often provide maternity care in rural and underserved communities, which offers the benefit of keeping women with low- or moderate-risk pregnancies in their local communities. The closure of maternity wards not only diminishes access to essential prenatal and postnatal care but also poses significant risks to the health and safety of expectant mothers and their newborns. Without local access to these vital services, pregnant women are forced to travel long distances for care, which can lead to delays in receiving necessary medical attention. This is particularly concerning in cases of high-risk pregnancies or emergency situations where every moment is crucial. Moreover, the closure of labor and delivery units can exacerbate health disparities, especially in rural and underserved communities. These areas already face significant obstacles in accessing health care services, and the loss of local maternity wards further increases the risk of adverse birth outcomes, including preterm births and low birth weight. The ripple effects of such closures extend beyond immediate health concerns, impacting the overall well-being and socioeconomic stability of communities.
   
   The cosponsors conclude that requiring facilities to report on the number of births, staffing levels, and fiscal condition will provide valuable data to better understand the challenges the labor and delivery units face and will enable targeted interventions to support the sustainability of labor and delivery units and ensure that every family has access to safe, quality maternal care.
   
4. CONCERNS. The California Hospital Association (CHA) states that they have concerns with this bill. CHA notes that CHA supports transparency and understands the desire for earlier notification on Labor and Delivery (L&D) closures. However, hospitals already provide a 90 day public notification and a 90 day notification to DPH when closing or reducing a service. CHA is concerned that notification of potential closures would exacerbate the existing challenges as health care providers and staff leave their jobs after learning that a facility is at risk of closure and prospective patients would be dissuaded from seeking care at a facility that may close, resulting in diminished patient volume. Hospitals typically do not know 12 months in advance that they may need to close an L&D unit. There are many factors hospitals must consider when making this difficult decision; however, it is often an unforeseen circumstance that ultimately pushes the hospital to decide to close its L&D unit.

Finally, CHA states that most of the data that hospitals would be required to report is data that they already report to HCAI on an annual or quarterly basis and is publicly available and a more streamlined approach to reporting could help avoid duplicative data submissions.

1. RELATED LEGISLATION. SB 1300 (Cortese) extends the public notice requirement when a health facility eliminates a supplemental service, currently 90 days prior to elimination of the service, to instead be 120 days when it involves the closure of either inpatient psychiatric services or maternity services. Requires a health facility that is eliminating an inpatient psychiatric or maternity supplemental service to complete an impact analysis report prior to providing notice of the proposed elimination of the supplemental service, and requires HCAI to prepare a form for this report and to review and certify the impact analyses. SB 1300 is pending in the Senate Appropriations Committee.
2. PREVIOUS LEGISLATION.
   1. AB 2037 (Wicks), Chapter 95, Statutes of 2020, increased the period of time when a hospital is required to provide public notice of a proposed closure or elimination of a supplemental service, from 90 days for the closure or downgrading of emergency services and 30 days for all other closures or eliminations of supplemental services, to 180 days prior to the elimination or downgrading of emergency services, 120 days prior to the closure of a hospital, and 90 days prior to the elimination of any other supplemental service.
   2. AB 1014 (O’Donnell) of 2019 would have increased the period of time when a hospital is required to provide public notice of a proposed closure or elimination of a supplemental service, from 90 days for the closure or downgrading of emergency services and 30 days for all other closures or eliminations of supplemental services, to 180 days prior to the closure of a hospital or the elimination or downgrading of emergency services, and 90 days prior to the elimination of any other supplemental service. AB 1014 was vetoed by the Governor, who stated the following in his veto message: “I agree that hospital closures have vast impacts on communities. However, this bill would not change the fact that the State is not able to force a hospital to stay open when they are financially unable. I am concerned that this bill may exacerbate the financial and patient safety concerns that often lead to closures.”
   3. AB 2874 (Thurmond) of 2018 would have required any hospital that provides EMS to notify the Attorney General no later than 180 days prior to a planned reduction or elimination of the level of EMS. AB 2874 failed passage on the Assembly Floor.
   4. SB 687 (Skinner) of 2017 would have required a nonprofit corporation that operates a health facility that includes a licensed emergency center to obtain the consent of the Attorney General prior to a planned elimination or reduction in the level of EMS provided. SB 687 was vetoed by Governor Brown.
   5. AB 2400 (Price), Chapter 459, Statutes of 2008, requires hospitals, not less than 30 days prior to closing a general acute care or acute psychiatric hospital, eliminating a supplemental service, as defined in existing regulations, or relocating the provision of a supplemental service to a different campus, to provide notice to the public and the applicable administering state department.
3. POLICY COMMENTS.
   1. Confidential information? This bill requires a hospital to report various information to HCAI when the hospital believes the maternity ward may be at risk of closure, and requires the information to be kept confidential to the extent permitted by law. However, much of the information is already reported to HCAI and is publicly accessible. Moving forward, the author may wish to work with stakeholders and HCAI to ensure that publicly available data is not inadvertently made confidential by the provisions of this bill.
   2. Financial distress. This bill requires a hospital, when assessing the risk of closure of maternity services, to consider factors, including, but not limited to, financial distress, workforce shortages, decreased demand in services, and birthing volume. As this bill moves forward, the author may wish to work with stakeholders and HCAI to develop specific metrics to assessment of financial health.

REGISTERED SUPPORT / OPPOSITION:

Support

American College of Obstetricians and Gynecologists District IX (cosponsor)
Reproductive Freedom for All (cosponsor)
California Medical Association
California Women's Law Center
Cleanearth4kids.org
Mee Memorial Healthcare System
San Francisco Women's Political Committee

Opposition

None on file.

Analysis Prepared by: Lara Flynn / HEALTH / (916) 319-2097