Existing law, the Compassionate Access to Medical Cannabis Act or Ryans Law, requires specified types of health care facilities to allow a terminally ill patients use of medicinal cannabis within the health care facility, as defined, subject to certain restrictions. Existing law requires that health care facilities permitting patient use of medicinal cannabis comply with other drug and medication requirements, as specified, and makes those facilities subject to enforcement actions by the State Department of Public Health. Existing law authorizes a health care facility to suspend compliance with these provisions if a regulatory agency, the United States Department of Justice, or the federal Centers for Medicare and Medicaid Services takes specified actions, including initiating an enforcement action against a health care facility related to the facilitys compliance with a state-regulated medical marijuana program.

This bill would expand those provisions to a patient who is over 65 years of age with a chronic disease. The bill would expand the definition of health care facility to also include a home health agency, as defined. The bill would additionally require a health care facility permitting patient use of medicinal cannabis, as specified, to ensure a denial of admission to the health care facility is not because of the patients use of medicinal cannabis. The bill would also authorize a health care facility to suspend compliance with these provisions if a regulatory agency, the United States Department of Justice, or the federal Centers for Medicare and Medicaid Services makes an inquiry about the health care facilitys activities.

Existing law, the Compassionate Access to Medical Cannabis Act or Ryans Law, requires specified types of health care facilities to allow a terminally ill patients use of medicinal cannabis within the health care facility, as defined, subject to certain restrictions. Existing law requires that health care facilities permitting patient use of medicinal cannabis comply with other drug and medication requirements, as specified, and makes those facilities subject to enforcement actions by the State Department of Public Health. Existing law authorizes a health care facility to suspend compliance with these provisions if a regulatory agency, the United States Department of Justice, or the federal Centers for Medicare and Medicaid Services takes specified actions, including initiating an enforcement action against a health care facility related to the facilitys compliance with a state-regulated medical marijuana program.

This bill would expand those provisions to a patient who is over 65 years of age with a chronic disease. The bill would expand the definition of health care facility to also include a home health agency, as defined. The bill would additionally require a health care facility permitting patient use of medicinal cannabis, as specified, to ensure a denial of admission to the health care facility is not because of the patients use of medicinal cannabis. The bill would also authorize a health care facility to suspend compliance with these provisions if a regulatory agency, the United States Department of Justice, or the federal Centers for Medicare and Medicaid Services makes an inquiry about the health care facilitys activities.

Existing law, the Compassionate Access to Medical Cannabis Act or Ryans Law, requires specified types of health care facilities to allow a terminally ill patients use of medicinal cannabis within the health care facility, as defined, subject to certain restrictions. Existing law requires that health care facilities permitting patient use of medicinal cannabis comply with other drug and medication requirements, as specified, and makes those facilities subject to enforcement actions by the State Department of Public Health. Existing law authorizes a health care facility to suspend compliance with these provisions if a regulatory agency, the United States Department of Justice, or the federal Centers for Medicare and Medicaid Services takes specified actions, including initiating an enforcement action against a health care facility related to the facilitys compliance with a state-regulated medical marijuana program.

This bill would expand those provisions to a patient who is over 65 years of age with a chronic disease, as defined. disease. The bill would expand the definition of health care facility to also include a home health agency, except as specified. agency, as defined. The bill would additionally require a health care facility permitting patient use of medicinal cannabis cannabis, as specified, to ensure a denial of admission to the health care facility is not because of the patients use of medicinal cannabis. The bill would also authorize a health care facility to suspend compliance with these provisions if a regulatory agency, the United States Department of Justice, or the federal Centers for Medicare and Medicaid Services makes an inquiry about the health care facilitys activities.

Existing law, the Compassionate Access to Medical Cannabis Act or Ryans Law, requires specified types of health care facilities to allow a terminally ill patients use of medicinal cannabis within the health care facility, as defined, subject to certain restrictions. Existing law requires that health care facilities permitting patient use of medical medicinal cannabis comply with other drug and medication requirements, as specified, and makes those facilities subject to enforcement actions by the State Department of Public Health.

This bill would expand those provisions to a patient who is over 65 years of age with a chronic disease, as defined. The bill would expand the definition of health care facility to also include a home health agency, except as specified. The bill would additionally require a health care facility permitting patient use of medicinal cannabis to ensure a denial of admission to the health care facility is not because of the patients use of medicinal cannabis.

Existing law, the Compassionate Access to Medical Cannabis Act or Ryans Law, requires specified types of health care facilities to allow a terminally ill patients use of medicinal cannabis within the health care facility, subject to certain restrictions. Existing law requires that health care facilities permitting patient use of medical cannabis comply with other drug and medication requirements, as specified, and makes those facilities subject to enforcement actions by the State Department of Public Health.

This bill would expand those provisions to a patient who is over 65 years of age with a chronic disease, as defined.

Existing law, the Compassionate Access to Medical Cannabis Act or Ryans Law, requires specified types of health care facilities to allow a terminally ill patients use of medicinal cannabis within the health care facility, subject to certain restrictions. Existing law requires that health care facilities permitting patient use of medical cannabis comply with other drug and medication requirements, as specified, and makes those facilities subject to enforcement actions by the State Department of Public Health.

This bill would expand those provisions to a patient who is over 65 years of age with a chronic disease, as defined.

 UNFINISHED BUSINESS  

Bill No: SB 302

Author: Stern (D), et al.

Amended: 9/7/23

Vote: 21

SENATE HEALTH COMMITTEE: 12-0, 3/29/23

AYES: Eggman, Nguyen, Glazer, Gonzalez, Grove, Hurtado, Limón, Menjivar, Roth, Rubio, Wahab, Wiener

SENATE JUDICIARY COMMITTEE: 11-0, 4/18/23

AYES: Umberg, Wilk, Allen, Ashby, Caballero, Durazo, Laird, McGuire, Min, Niello, Wiener

SENATE APPROPRIATIONS COMMITTEE: 7-0, 5/18/23

AYES: Portantino, Jones, Ashby, Bradford, Seyarto, Wahab, Wiener

SENATE FLOOR: 39-0, 5/24/23

AYES: Allen, Alvarado-Gil, Archuleta, Ashby, Atkins, Becker, Blakespear, Bradford, Caballero, Cortese, Dahle, Dodd, Durazo, Eggman, Glazer, Gonzalez, Grove, Hurtado, Jones, Laird, McGuire, Menjivar, Min, Newman, Nguyen, Niello, Ochoa Bogh, Padilla, Portantino, Roth, Rubio, Seyarto, Skinner, Smallwood-Cuevas, Stern, Umberg, Wahab, Wiener, Wilk

NO VOTE RECORDED: Limón

ASSEMBLY FLOOR: 64-0, 9/14/23

(ROLL CALL VOTE NOT AVAILABLE)

SUBJECT: Compassionate Access to Medical Cannabis Act

SOURCE: Author

DIGEST:

This bill expands existing law requiring health facilities to permit terminally ill patients to have access to their medical cannabis to also require health facilities to permit patients who are over 65 years of age and have a chronic disease to have access to their medical cannabis, and includes home health agencies in the list of health facilities included in this law.

Assembly Amendments

expand access to medical cannabis to patients receiving care from a home health agency, prohibit the smoking or vaping of cannabis in a home immediately before or while home health agency staff are present in the residence, and prohibit hospitals from permitting a patient with a chronic disease from using medicinal cannabis.

ANALYSIS:

Existing law:

1. Licenses and regulates various health facilities, including clinics, hospitals, skilled nursing facilities, intermediate care facilities, congregate living health facilities, correctional treatment facilities, and hospice facilities by the California Department of Public Health (CDPH). Licenses and regulates residential care facilities for the elderly by the Department of Social Services. [HSC §1200, §1250, and §1569]
2. Establishes the Compassionate Use Act (CUA) of 1996, also known as Proposition 215, which protects patients and their primary caregivers from criminal prosecution or sanction for obtaining and using marijuana for medical purposes upon the recommendation of a physician. Protects physicians who recommends marijuana to a patient for medical purposes from being punished or denied any right or privilege. States that the purpose of CUA is to ensure that seriously ill Californians have the right to obtain and use marijuana if a physician has determined that the person’s health would benefit from its use in the treatment of cancer, anorexia, AIDS, chronic pain, spasticity, glaucoma, arthritis, migraine, or any other illness for which marijuana provides relief. [HSC §11362.5]
3. Establishes the Compassionate Access to Medical Cannabis Act, or “Ryan’s Law,” to require health facilities to permit patient use of medical cannabis in order to support the ability of a terminally ill patient to safely use medicinal cannabis in compliance with the CUA. [HSC §1649 et seq.]
4. Requires a health facility, under Ryan’s Law, including hospitals, skilled nursing facilities, intermediate care facilities, and others, to permit patients who are terminally ill with a prognosis of life of one year or less to use medical cannabis. [HSC §1649.2]
5. Prohibits, under Ryan’s Law, smoking or vaping as methods to use medical cannabis. [HSC §1649.2 (a)]
6. Requires a patient or primary caregiver to be responsible for acquiring, retrieving, administering, and removing medicinal cannabis. Requires medicinal cannabis to be stored securely at all times in a locked container in the patient’s room or with the patient’s primary caregiver, and prohibits health care professionals and facility staff from administering medicinal cannabis or retrieving medicinal cannabis from storage. [HSC §1649.2 (d)€(f)]
7. Prohibits compliance with Ryan’s Law from being a condition for obtaining, retaining, or renewing a license as a health facility. [HSC §1649.5]
8. Permits a health facility to suspend compliance with Ryan’s Law if a federal regulatory agency initiates enforcement action against a health care facility related to medical marijuana, or a federal regulatory agency otherwise provides notification to the health facility that expressly prohibits the use of medical marijuana in health care facilities. [HSC §1649.6]
9. Establishes the California Uniform Controlled Substances Act, which among other things, classifies controlled substances into five schedules according to their danger and potential for abuse, and classifies cannabis as a Schedule I controlled substance. [HSC §11000, et seq., §11054(d)(13)]

This bill:

1. Expands Ryan’s Law, which requires health facilities to permit patients who are terminally ill to use medical cannabis, to also allow medical cannabis access to patients who are over 65 years of age and have a chronic disease for which the patient has received a physician’s assessment declaring that the patient has a serious medical condition, as defined in existing law governing the use of medical marijuana, and that the use of medicinal cannabis is appropriate.
2. Expands the type of facilities subject to Ryan’s Law to include licensed home health agencies, as defined.
3. Requires a home health agency to prohibit smoking or vaping immediately before or while home health agency staff are present in the residence.
4. Exempts home health agencies from the requirement that medicinal cannabis be stored securely at all times in a locked container, that all remaining medicinal cannabis be removed or disposed upon discharge, and from the requirement to develop and disseminate written guidelines for the use and disposal of medicinal cannabis within the health care facility.
5. Prohibits a health facility from denying a patient admission to the health care facility in whole or in part because of the patient’s use of medicinal cannabis.
6. Prohibits a general acute care hospital from permitting a patient with a chronic disease from using medicinal cannabis.

Comments

1. Author’s statement. According to the author, the National Council on Aging reports that nearly 95% of people over 65 have one chronic condition and nearly 80% have two or more. Patients using medicinal marijuana to treat a variety of chronic illnesses have unfettered access outside of healthcare facilities. However, elderly patients who live in medically assisted facilities are not afforded this same right. As a caregiver to my elderly stepfather who experiences chronic illness and utilizes cannabis in his treatment plan, I am struck that my only option to continue his most effective means of care is to keep him at home. As the law stands, when his needs become too great for our family’s capacity, he will no longer have access to this vital resource that dramatically elevates his quality of life until his life is nearly over. With the passage of SB 311 (Hueso, Chapter 384, Statutes of 2021), we have already seen the Legislature recognize the utility of cannabis in medical treatment. This bill simply allows the same access to more individuals who find benefit in it. Our elderly deserve all viable and effective options to treat chronic disease in any medical setting.
2. Background on medical marijuana. California was the first state in the nation to allow for the medical use of marijuana with the passage of Proposition 215 in 1996. Since then, according to the National Conference of State Legislatures, 33 more states, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands have enacted similar laws. Following enactment of Proposition 215 (CUA), the Institute of Medicine issued a report in 1999 stating that scientific data indicate the “potential therapeutic value of cannabinoid drugs, primarily THC, for pain relief, control of nausea and vomiting, and appetite stimulation.” The report went on to state that the psychological effects of cannabinoids, such as anxiety reduction, sedation, and euphoria can influence their potential therapeutic value. More recently, in January 2017, the National Academies of Sciences, Engineering, and Medicine published a review of the scientific research on cannabis published since 1999, considering more than 10,000 scientific abstracts to reach nearly 100 conclusions. This review found evidence to support that patients who were treated with cannabis or cannabinoids were more likely to experience significant reductions in pain symptoms. It also found benefits for multiple sclerosis-related muscle spasms, and preventing and treating chemotherapy-induced nausea and vomiting. Along with certain benefits, the review of the science suggested cannabis is likely to increase the risk of developing schizophrenia and other psychoses, and that with greater frequency of cannabis use, there is an increased likelihood of developing problem cannabis use.
3. Background on medical marijuana in hospitals. ACP Hospitals, a publication of the American College of Physicians, published an article in January 2017 entitled “Medical marijuana…in the hospital?” According to this article, with medical marijuana laws now in effect in more than half the country, hospitals are seeing more patients who have been certified to use the drug, and they are developing policies and practices in response. According to this article, as of May 2016, state laws in Connecticut and Maine permit the use of medical marijuana by hospitalized patients and give some state-level legal protection for clinicians who administer it. However, with regard to Maine, where medical cannabis has been legal for years and even with state law permitting use in a hospital, hospitals commonly prohibit the use of the drug in their facilities. In 2015, a Maine- registered marijuana patient, hospitalized with a blood infection, tried to treat himself by rubbing an infused lotion onto his hand to relieve pain and stiffness from carpal tunnel. The hospital told the patient to remove the substance from the hospital or it would be confiscated. Elsewhere, according to the ACP Hospitals article, the Minnesota Hospital Association came up with three sample policies with three clear stances that hospitals can take on the issue: one template for hospitals that choose to prohibit medical cannabis in their facilities; a second template for hospitals that choose to allow patients to be able to continue their use of cannabis while in the hospital with self-directed therapy; and a third template for hospitals that choose to incorporate the patient’s use of cannabis in the hospital’s medication process. The article pointed to the Mayo Clinic’s hospitals permitting use by patients registered with Minnesota’s medical marijuana program who come into the hospital with a cannabis product in its original container as dispensed by an approved cannabis patient center.

Related/Prior Legislation

SB 988 (Hueso, Chapter 242, Statutes of 2022) revised Ryan’s Law by repealing the requirement that health facilities comply with drug and medication requirements applicable to Schedule II, III, and IV drugs when permitting patient use of medicinal cannabis, and instead required the patient or primary caregiver to be responsible for acquiring, retrieving, administering, and removing medicinal cannabis. Required medicinal cannabis to be stored in a locked container in the patient’s room or with the patient’s primary caregiver, and prohibited healthcare professionals and facility staff from administering medicinal cannabis or retrieving it from storage.

SB 311 (Hueso, Chapter 384, Statutes of 2021) enacted Ryan’s Law to require a health care facility to permit a terminally ill patient, defined as a prognosis of one year or less to live, to use medical cannabis within the health care facility.

SB 305 (Hueso, 2019) was similar to SB 311, but was vetoed by Governor Newsom. In his veto message, the Governor stated that “It is inconceivable that the federal government continues to regard cannabis as having no medicinal value. The federal government’s ludicrous stance puts patients and those who care for them in an unconscionable position. Nonetheless, health facilities certified to receive payment from the federal Center for Medicare and Medicaid Services must comply with all federal laws in order to receive federal reimbursement for the services they provide. This bill would create significant conflicts between federal and state law that cannot be taken lightly. Therefore, I begrudgingly veto this bill.”

SB 223 (Hill, Chapter 699, Statutes of 2019) authorized the governing board of a school district, a county board of education, or the governing body of a charter school maintaining kindergarten or any of grades 1 to 12, to adopt a policy that allows a parent or guardian of a pupil to possess and administer non-smokeable and non-vapeable medicinal cannabis to the authorized pupil at a school site.

SB 94 (Committee on Budget and Fiscal Review, Chapter 27, Statutes of 2017) established a single system of administration for cannabis laws in California, combining the Medical Cannabis Regulation and Safety Act with the Adult Use of Marijuana Act.

AB 266 (Bonta, Chapter 689, Statutes of 2015), SB 643 (McGuire, Chapter 719, Statutes of 2015), and AB 243 (Wood, Chapter 688, Statutes of 2015) was a package of bills that established a licensing and regulatory framework for medical marijuana under the Medical Marijuana Regulation and Safety Act.

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

According to the Senate Appropriations Committee, unknown costs, potentially hundreds of thousands, for CDPH to administer and oversee the provisions.

SUPPORT: (Verified 9/7/23)

Americans for Safe Access

California Cannabis Coalition

California Health Coalition Advocacy

California NORML

Society of Cannabis Clinicians

UDW/AFSCME Local 3930

Weed for Warriors

4 individuals

OPPOSITION: (Verified 9/7/23)

Department of Finance

ARGUMENTS IN SUPPORT: California Health Coalition Advocacy states in support that the use of medicinal cannabis has the potential to decrease dependence on opioids for the management of chronic pain, and that patients looking for alternative options for pain relief should have access to medicinal cannabis.

California NORML states in support that a 2017 UC Berkeley Study reported that 97% of a statewide sample of medicinal cannabis users agreed that they are able to decrease the amount of opiates they consume when they also use cannabis, and 81% agreed that taking cannabis by itself was more effective at treating their condition than taking opioids.

UDW/AFSCME Local 3920 states in support that according to the National Council on Aging, approximately 95% of persons over the age of 65 have one chronic illness, and nearly 80% have two or more. Outside of health care facilities, those who utilize medical marijuana to treat a range of chronic conditions have unrestricted access, but older individuals living in medically assisted institutions do not have that same luxury and have no choice but to continue the use of opioids.

ARGUMENTS IN OPPOSITION: The Department of Finance opposes this bill as it creates additional and ongoing cost pressures to CDPH’s Licensing and Certification Fund, and notes that to the extent there are multiple bills chaptered which result in Licensing and Certification Fund expenditures, there may need to be a corresponding fee increase.

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

9/14/23 15:34:06

**** END ****

SENATE THIRD READING

STR Bill Id:SB 302

Author:(Stern)

As Amended Ver:September 7, 2023

Majority vote

SUMMARY

Expands existing law requiring health facilities to permit terminally ill patients to have access to medical cannabis to also require health facilities, except general acute care hospitals, to permit patients who are over 65 years of age and have a chronic disease, to have access to medical cannabis. Prohibits home health agencies (HHAs) from withholding care to individuals utilizing cannabis for medical purposes, and requires HHAs to prohibit smoking or vaping immediately before or while HHA staff are present in a residence. Defines a chronic disease to mean a condition that lasts one or more years and requires ongoing medical attention or limits the activities of daily living, or both. Ensures that a patient is not denied admission to a health care facility because of the patient's use of medical cannabis. Adds an inquiry by a federal regulatory agency about a California health facility’s activities pursuant to the Compassionate Access to Medical Cannabis Act (Ryan’s Law) to the list of actions allowing a facility to suspend compliance with Ryan’s Law, including a notice to suspend funding.

Major Provisions

COMMENTS

1. Medical cannabis. Medical cannabis can be helpful in treating a variety of conditions. The specific disorders it can legally be used to treat vary from state to state. To date, it appears to be most effective for treating muscle spasms, chronic pain, and nausea. The United States (U.S.) Food and Drug Administration (FDA) recently approved a form of medical cannabis to treat severe childhood epilepsy. Marijuana comes from the Cannabis plant. In its leaves and buds are substances called cannabinoids. The plant contains more than 100 cannabinoids, but two are of particular interest for medical purposes: THC (delta-9 tetrahydrocannabinol) and CBD (cannabidiol). THC is the primary mind-altering ingredient in marijuana that makes people "high." CBD does not trigger changes in the brain that lead to a high.

Possession of marijuana is illegal under federal law in the U.S. However, over 30 states and the District of Columbia currently have laws legalizing medical cannabis in some form, California being the first with the passage of Proposition 215 in 1996. As noted in existing law above, Californians have the right to obtain and use marijuana if a physician has determined that the person's health would benefit from its use in the treatment of cancer, anorexia, AIDS, chronic pain, spasticity, glaucoma, arthritis, migraine, or any other illness for which marijuana provides relief.

A 2017 report from the National Academies of Science, "The Health Effects of Cannabis and Cannabinoids," reviewed and summarized the medical literature published about medical cannabis, specifically examining its effectiveness and safety. It concluded that medical cannabis was particularly effective for easing chronic pain, especially pain caused by nerve damage. It can effectively control nausea and vomiting and is often used to manage those symptoms in people undergoing chemotherapy.

The National Institutes of Health notes that THC itself has proven medical benefits in particular formulations. The FDA has approved THC-based medications, dronabinol (Marinol^®) and nabilone (Cesamet^®), prescribed in pill form for the treatment of nausea in patients undergoing cancer chemotherapy and to stimulate appetite in patients with wasting syndrome due to AIDS.

Medical cannabis in hospitals. ACP Hospitals, a publication of the American College of Physicians, published an article in January 2017 entitled "Medical marijuana…in the hospital?" According to this article, with medical marijuana laws now in effect in more than half the country, hospitals are seeing more patients who have been certified to use the drug, and they are developing policies and practices in response. According to this article, as of May 2016, state laws in Connecticut and Maine permit the use of medical marijuana by hospitalized patients and give some state-level legal protection for clinicians who administer it. According to the ACP Hospitals article, the Minnesota Hospital Association has come up with three sample policies with three clear stances that hospitals can take on the issue: one template for hospitals that choose to prohibit medical cannabis in their facilities; a second template for hospitals that choose to allow patients to be able to continue their use of cannabis while in the hospital with self-directed therapy; and, a third template for hospitals that choose to incorporate the patient's use of cannabis in the hospital’s medication process. The article pointed to the Mayo Clinic's hospitals permitting use by patients registered with Minnesota’s medical marijuana program who come into the hospital with a cannabis product in its original container as dispensed by an approved cannabis patient center.

California law currently allows terminally ill patients to use medical cannabis in general acute care hospitals (GACHs), skilled nursing facilities (SNFs), special hospitals, congregate living health facilities (CLHFs), and hospice facilities. This bill expands existing law to also permit medical cannabis use by patients who are over 65 years of age and have a chronic disease, and prohibits HHAs from withholding care to individuals utilizing cannabis for medical purposes.

1. Federal law and changing enforcement. At the federal level, marijuana is classified as a Schedule I substance under the Uniform Controlled Substances Act, where Schedule I substances are considered to have a high potential for dependency and no accepted medical use, which makes distribution of marijuana a federal offense. In October of 2009, the Obama Administration sent a memo to federal prosecutors encouraging them not to prosecute people who distribute marijuana for medical purposes in accordance with state law. In August of 2013, the U.S. Department of Justice (DOJ) provided an update to its marijuana enforcement policy in the aftermath of Colorado and Washington voting to legalize non-medical use of marijuana. This memo, known as the "Cole Memorandum," stated that while marijuana remains illegal federally, the DOJ expects states like Colorado and Washington to create "strong, state-based enforcement efforts…and will defer the right to challenge their legalization laws at this time." However, in January 2018, former U.S. Attorney General Sessions issued a Marijuana Enforcement Memorandum that rescinded the Cole Memorandum, and permitted federal prosecutors to decide how to prioritize enforcement of federal marijuana laws, weighing “all relevant considerations, including federal law enforcement priorities set by the Attorney General, the seriousness of the crime, the deterrent effect of criminal prosecution, and the cumulative impact of particular crimes on the community."

In remarks in front of a Senate Appropriations subcommittee hearing on April 26, 2022, Attorney General Merrick Garland stated that the DOJ will not prioritize persecuting marijuana use. While President Biden campaigned on decriminalizing marijuana, there has been no significant progress toward making marijuana legal at the federal level.

1. Chronic disease in California. According to the California Health Care Foundation 2020 report (CHCF report), "Quality of Care: Chronic Conditions," many Californians suffer from chronic disease. Chronic conditions such as diabetes and heart disease were the leading cause of death and disability in the United States. In 2018, high blood pressure was the most common chronic condition, affecting three in 10 adults in California. In 2018, over one in four adults in California was obese. About four in 10 Black adults in California was obese. One in three adults with Medi-Cal coverage was obese, the highest rate of any payer group. Black Californians had higher mortality rates for breast, prostate, lung, and colorectal cancer than Asian, Latino, and white Californians in 2017. The largest disparity was with prostate cancer, where Black men had mortality rates that were two times higher than the rate for Latino and white men and four times higher than the rate for Asian men.

The CHCF report notes that in California, nearly 700 hospitalizations per 100,000 people were potentially preventable through effective chronic care management and access to high-quality primary care, based on a composite measure of hospital admission rates for eight chronic care conditions. The preventable hospitalization rate varied from a low of 129 in Mono County to a high of 1,341 in Butte County.

According to the Author

The National Council on Aging reports that nearly 95% of people over 65 have one chronic condition and nearly 80% have two or more. Patients using medicinal marijuana to treat a variety of chronic illnesses have unfettered access outside of healthcare facilities. However, elderly patients who live in medically assisted facilities are not afforded this same right. The author states that as a caregiver to his elderly stepfather who experiences chronic illness and utilizes cannabis in his treatment plan, he is struck that the only option to continue his most effective means of care is to keep him at home. As the law stands, when his needs become too great for their family’s capacity, he will no longer have access to this vital resource that dramatically elevates his quality of life until his life is nearly over. The author notes that with the passage of SB 311 (Hueso), Chapter 384, Statutes of 2021, the Legislature recognized the utility of cannabis in medical treatment. This bill simply allows the same access to more individuals who find benefit in it. The author concludes that the elderly deserve all viable and effective options to treat chronic disease in any medical setting.

Arguments in Support

The Society of Cannabis Clinicians (SCC), supports this bill and points to a National Council on Aging report that shows nearly 95% of people over 65 have one chronic condition and nearly 80% have two or more. SCC states that patients using medical cannabis to treat a variety of chronic illnesses have unfettered access outside of healthcare facilities, however, elderly patients who live in medically assisted facilities are not afforded this same right. These patients who suffer with pain continue to use opioids for many chronic conditions despite their limited long-term efficacy and adverse side effects. SCC also points to a 2017 UC Berkeley study that reported that 97% of a statewide sample of medicinal cannabis users agreed that they are able to decrease the amount of opiates they consume when they also use cannabis, and 81% agreed that taking cannabis by itself was more effective at treating their condition than taking opioids.

California Health Coalition Advocacy supports this bill and notes that the use of medicinal cannabis has the potential to decrease dependence on opioids for the management of chronic pain, and that patients looking for alternative options for pain relief should have access to medicinal cannabis.

Arguments in Opposition

The Department of Finance opposes this bill as it creates additional and ongoing cost pressure on the Licensing and Certification Fund. Finance notes that to the extent there are multiple bills chaptered which result in Licensing and Certification Fund expenditures, there may need be a corresponding Licensing and Certification Fund fee increase.

FISCAL COMMENTS

According to the Assembly Appropriations Committee, the California Department of Public Health (DPH) estimates costs of $900,000 in fiscal year (FY) 2023-24 and $1.5 million in FY 2024-25 and annually thereafter to fund eight additional positions to investigate an estimated 350 additional complaints at an average of 20 hours per investigation (Licensing and Certification Fund). DPH expects this bill to significantly increase the number of patients who will gain access to medicinal cannabis in SNFs, CLHFs, GACHs and hospice facilities. DPH anticipates it will receive more complaints about: 1) procedures facilities adopt to establish how patients will access, store, and use medicinal cannabis; 2) the inclusion of home health agencies under Ryan's Law; and 3) the prohibition on banning a patient’s admission to a facility because of their use of medicinal cannabis.

VOTES

SENATE FLOOR: 39-0-1

YES: Allen, Alvarado-Gil, Archuleta, Ashby, Atkins, Becker, Blakespear, Bradford, Caballero, Cortese, Dahle, Dodd, Durazo, Eggman, Glazer, Gonzalez, Grove, Hurtado, Jones, Laird, McGuire, Menjivar, Min, Newman, Nguyen, Niello, Ochoa Bogh, Padilla, Portantino, Roth, Rubio, Seyarto, Skinner, Smallwood-Cuevas, Stern, Umberg, Wahab, Wiener, Wilk

ABS, ABST OR NV: Limón

ASM HEALTH: 14-0-1

YES: Wood, Waldron, Aguiar-Curry, Arambula, Boerner, Wendy Carrillo, Vince Fong, Maienschein, McCarty, Joe Patterson, Rodriguez, Santiago, Villapudua, Weber

ABS, ABST OR NV: Flora

ASM APPROPRIATIONS: 16-0-0

YES: Holden, Megan Dahle, Bryan, Calderon, Wendy Carrillo, Dixon, Mike Fong, Hart, Lowenthal, Mathis, Papan, Pellerin, Sanchez, Soria, Weber, Wilson

UPDATED

VERSION: September 7, 2023

CONSULTANT: Lara Flynn / HEALTH / (916) 319-2097 FN: 0002088

SENATE THIRD READING

STR Bill Id:SB 302

Author:(Stern)

As Amended Ver:June 12, 2023

Majority vote

SUMMARY

Expands existing law requiring health facilities to permit terminally ill patients to have access to medical cannabis to also require health facilities to permit patients who are over 65 years of age and have a chronic disease, to have access to medical cannabis. Prohibits home health agencies (HHAs) from withholding care to individuals utilizing cannabis for medical purposes. Defines a chronic disease to mean a condition that lasts one or more years and requires ongoing medical attention or limits the activities of daily living, or both. Ensures that a patient is not denied admission to a health care facility because of the patient's use of medical cannabis.

Major Provisions

COMMENTS

1. Medical cannabis. Medical cannabis can be helpful in treating a variety of conditions. The specific disorders it can legally be used to treat vary from state to state. To date, it appears to be most effective for treating muscle spasms, chronic pain, and nausea. The United States (U.S.) Food and Drug Administration (FDA) recently approved a form of medical cannabis to treat severe childhood epilepsy. Marijuana comes from the Cannabis plant. In its leaves and buds are substances called cannabinoids. The plant contains more than 100 cannabinoids, but two are of particular interest for medical purposes: THC (delta-9 tetrahydrocannabinol) and CBD (cannabidiol). THC is the primary mind-altering ingredient in marijuana that makes people "high." CBD does not trigger changes in the brain that lead to a high.

Possession of marijuana is illegal under federal law in the U.S. However, over 30 states and the District of Columbia currently have laws legalizing medical cannabis in some form, California being the first with the passage of Proposition 215 in 1996. As noted in existing law above, Californians have the right to obtain and use marijuana if a physician has determined that the person's health would benefit from its use in the treatment of cancer, anorexia, AIDS, chronic pain, spasticity, glaucoma, arthritis, migraine, or any other illness for which marijuana provides relief.

A 2017 report from the National Academies of Science, "The Health Effects of Cannabis and Cannabinoids," reviewed and summarized the medical literature published about medical cannabis, specifically examining its effectiveness and safety. It concluded that medical cannabis was particularly effective for easing chronic pain, especially pain caused by nerve damage. It can effectively control nausea and vomiting and is often used to manage those symptoms in people undergoing chemotherapy.

The National Institutes of Health notes that THC itself has proven medical benefits in particular formulations. The FDA has approved THC-based medications, dronabinol (Marinol^®) and nabilone (Cesamet^®), prescribed in pill form for the treatment of nausea in patients undergoing cancer chemotherapy and to stimulate appetite in patients with wasting syndrome due to AIDS.

Medical cannabis in hospitals. ACP Hospitals, a publication of the American College of Physicians, published an article in January 2017 entitled "Medical marijuana…in the hospital?" According to this article, with medical marijuana laws now in effect in more than half the country, hospitals are seeing more patients who have been certified to use the drug, and they are developing policies and practices in response. According to this article, as of May 2016, state laws in Connecticut and Maine permit the use of medical marijuana by hospitalized patients and give some state-level legal protection for clinicians who administer it. According to the ACP Hospitals article, the Minnesota Hospital Association has come up with three sample policies with three clear stances that hospitals can take on the issue: one template for hospitals that choose to prohibit medical cannabis in their facilities; a second template for hospitals that choose to allow patients to be able to continue their use of cannabis while in the hospital with self-directed therapy; and, a third template for hospitals that choose to incorporate the patient's use of cannabis in the hospital’s medication process. The article pointed to the Mayo Clinic's hospitals permitting use by patients registered with Minnesota’s medical marijuana program who come into the hospital with a cannabis product in its original container as dispensed by an approved cannabis patient center.

California law currently allows terminally ill patients to use medical cannabis in general acute care hospitals (GACHs), skilled nursing facilities (SNFs), special hospitals, congregate living health facilities (CLHFs), and hospice facilities. This bill expands existing law to also permit medical cannabis use by patients who are over 65 years of age and have a chronic disease, and prohibits HHAs from withholding care to individuals utilizing cannabis for medical purposes.

1. Federal law and changing enforcement. At the federal level, marijuana is classified as a Schedule I substance under the Uniform Controlled Substances Act, where Schedule I substances are considered to have a high potential for dependency and no accepted medical use, which makes distribution of marijuana a federal offense. In October of 2009, the Obama Administration sent a memo to federal prosecutors encouraging them not to prosecute people who distribute marijuana for medical purposes in accordance with state law. In August of 2013, the U.S. Department of Justice (DOJ) provided an update to its marijuana enforcement policy in the aftermath of Colorado and Washington voting to legalize non-medical use of marijuana. This memo, known as the "Cole Memorandum," stated that while marijuana remains illegal federally, the DOJ expects states like Colorado and Washington to create "strong, state-based enforcement efforts…and will defer the right to challenge their legalization laws at this time." However, in January 2018, former U.S. Attorney General Sessions issued a Marijuana Enforcement Memorandum that rescinded the Cole Memorandum, and permitted federal prosecutors to decide how to prioritize enforcement of federal marijuana laws, weighing “all relevant considerations, including federal law enforcement priorities set by the Attorney General, the seriousness of the crime, the deterrent effect of criminal prosecution, and the cumulative impact of particular crimes on the community."

In remarks in front of a Senate Appropriations subcommittee hearing on April 26, 2022, Attorney General Merrick Garland stated that the DOJ will not prioritize persecuting marijuana use. While President Biden campaigned on decriminalizing marijuana, there has been no significant progress toward making marijuana legal at the federal level.

1. Chronic disease in California. According to the California Health Care Foundation 2020 report (CHCF report), "Quality of Care: Chronic Conditions," many Californians suffer from chronic disease. Chronic conditions such as diabetes and heart disease were the leading cause of death and disability in the United States. In 2018, high blood pressure was the most common chronic condition, affecting three in 10 adults in California. In 2018, over one in four adults in California was obese. About four in 10 Black adults in California was obese. One in three adults with Medi-Cal coverage was obese, the highest rate of any payer group. Black Californians had higher mortality rates for breast, prostate, lung, and colorectal cancer than Asian, Latino, and white Californians in 2017. The largest disparity was with prostate cancer, where Black men had mortality rates that were two times higher than the rate for Latino and white men and four times higher than the rate for Asian men.

The CHCF report notes that in California, nearly 700 hospitalizations per 100,000 people were potentially preventable through effective chronic care management and access to high-quality primary care, based on a composite measure of hospital admission rates for eight chronic care conditions. The preventable hospitalization rate varied from a low of 129 in Mono County to a high of 1,341 in Butte County.

According to the Author

The National Council on Aging reports that nearly 95% of people over 65 have one chronic condition and nearly 80% have two or more. Patients using medicinal marijuana to treat a variety of chronic illnesses have unfettered access outside of healthcare facilities. However, elderly patients who live in medically assisted facilities are not afforded this same right. The author states that as a caregiver to his elderly stepfather who experiences chronic illness and utilizes cannabis in his treatment plan, he is struck that the only option to continue his most effective means of care is to keep him at home. As the law stands, when his needs become too great for their family’s capacity, he will no longer have access to this vital resource that dramatically elevates his quality of life until his life is nearly over. The author notes that with the passage of SB 311 (Hueso), Chapter 384, Statutes of 2021, the Legislature recognized the utility of cannabis in medical treatment. This bill simply allows the same access to more individuals who find benefit in it. The author concludes that the elderly deserve all viable and effective options to treat chronic disease in any medical setting.

Arguments in Support

The Society of Cannabis Clinicians (SCC), supports this bill and points to a National Council on Aging report that shows nearly 95% of people over 65 have one chronic condition and nearly 80% have two or more. SCC states that patients using medical cannabis to treat a variety of chronic illnesses have unfettered access outside of healthcare facilities, however, elderly patients who live in medically assisted facilities are not afforded this same right. These patients who suffer with pain continue to use opioids for many chronic conditions despite their limited long-term efficacy and adverse side effects. SCC also points to a 2017 UC Berkeley study that reported that 97% of a statewide sample of medicinal cannabis users agreed that they are able to decrease the amount of opiates they consume when they also use cannabis, and 81% agreed that taking cannabis by itself was more effective at treating their condition than taking opioids.

California Health Coalition Advocacy supports this bill and notes that the use of medicinal cannabis has the potential to decrease dependence on opioids for the management of chronic pain, and that patients looking for alternative options for pain relief should have access to medicinal cannabis.

Arguments in Opposition

The Department of Finance opposes this bill as it creates additional and ongoing cost pressure on the Licensing and Certification Fund. Finance notes that to the extent there are multiple bills chaptered which result in Licensing and Certification Fund expenditures, there may need be a corresponding Licensing and Certification Fund fee increase.

FISCAL COMMENTS

According to the Assembly Appropriations Committee, the California Department of Public Health (DPH) estimates costs of $900,000 in fiscal year (FY) 2023-24 and $1.5 million in FY 2024-25 and annually thereafter to fund eight additional positions to investigate an estimated 350 additional complaints at an average of 20 hours per investigation (Licensing and Certification Fund). DPH expects this bill to significantly increase the number of patients who will gain access to medicinal cannabis in SNFs, CLHFs, GACHs and hospice facilities. DPH anticipates it will receive more complaints about: 1) procedures facilities adopt to establish how patients will access, store, and use medicinal cannabis; 2) the inclusion of home health agencies under Ryan's Law; and 3) the prohibition on banning a patient’s admission to a facility because of their use of medicinal cannabis

VOTES

SENATE FLOOR: 39-0-1

YES: Allen, Alvarado-Gil, Archuleta, Ashby, Atkins, Becker, Blakespear, Bradford, Caballero, Cortese, Dahle, Dodd, Durazo, Eggman, Glazer, Gonzalez, Grove, Hurtado, Jones, Laird, McGuire, Menjivar, Min, Newman, Nguyen, Niello, Ochoa Bogh, Padilla, Portantino, Roth, Rubio, Seyarto, Skinner, Smallwood-Cuevas, Stern, Umberg, Wahab, Wiener, Wilk

ABS, ABST OR NV: Limón

ASM HEALTH: 14-0-1

YES: Wood, Waldron, Aguiar-Curry, Arambula, Boerner, Wendy Carrillo, Vince Fong, Maienschein, McCarty, Joe Patterson, Rodriguez, Santiago, Villapudua, Weber

ABS, ABST OR NV: Flora

ASM APPROPRIATIONS: 16-0-0

YES: Holden, Megan Dahle, Bryan, Calderon, Wendy Carrillo, Dixon, Mike Fong, Hart, Lowenthal, Mathis, Papan, Pellerin, Sanchez, Soria, Weber, Wilson

UPDATED

VERSION: June 12, 2023

CONSULTANT: Lara Flynn / HEALTH / (916) 319-2097 FN: 0001604

Date of Hearing: August 23, 2023

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Chris Holden, Chair

SBPCA Bill Id:SB 302

Author:(Stern) – As Amended Ver:June 12, 2023

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

SUMMARY:

This bill expands the Compassionate Access to Medical Cannabis Act (Ryan’s Law), which requires a health facility to allow terminally ill patients to have access to medicinal cannabis, to also allow a patient who is over 65 years of age with a chronic disease to use medicinal cannabis. This bill also adds home health agencies to the health facilities that must allow certain patients’ access to medicinal cannabis.

This bill defines chronic disease as a condition that lasts one or more years and requires ongoing medical attention or limits the activities of daily living, or both. The bill also requires a health care facility to ensure that a patient is not denied admission to the facility in whole or in part because of the patient’s use of medicinal cannabis.

FISCAL EFFECT:

The California Department of Public Health (CDPH) estimates costs of $900,000 in fiscal year (FY) 2023-24 and $1.5 million in FY 2024-25 and annually thereafter to fund eight additional positions to investigate an estimated 350 additional complaints at an average of 20 hours per investigation (Licensing and Certification Fund).

CDPH expects this bill to significantly increase the number of patients who will gain access to medicinal cannabis in Skilled Nursing Facilities, Congregate Living Health Facilities, General Acute Care Hospitals, and hospice facilities. CDPH anticipates it will receive more complaints about: 1) procedures facilities adopt to establish how patients will access, store, and use medicinal cannabis; 2) the inclusion of home health agencies under Ryan’s Law; and 3) the prohibition on banning a patient’s admission to a facility because of their use of medicinal cannabis.

COMMENTS:

1. Purpose. According to the author:

The National Council on Aging reports that nearly 95% of people over 65 have one chronic condition and nearly 80% have two or more. Patients using medicinal marijuana to treat a variety of chronic illnesses have unfettered access outside of healthcare facilities. However, elderly patients who live in medically assisted facilities are not afforded this same right. As a caregiver to my elderly stepfather who experiences chronic illness and utilizes cannabis in his treatment plan, I am struck that my only option to continue his most effective means of care is to keep him at home. As the law stands, when his needs become too great for our family’s capacity, he will no longer have access to this vital resource that dramatically elevates his quality of life until his life is nearly over. With the passage of SB 311 (2021) we have already seen the legislature recognize the utility of cannabis in medical treatment. This bill simply allows the same access to more individuals who find benefit in it. Our elderly deserve all viable and effective options to treat chronic disease in any medical setting.

1. Prior Legislation.
   1. SB 988 (Hueso), Chapter 242, Statutes of 2022, revised Ryan’s Law by repealing the requirement that health facilities comply with drug and medication requirements applicable to Schedule II, III, and IV drugs when permitting patient use of medicinal cannabis, and instead requires the patient or primary caregiver to be responsible for acquiring, retrieving, administering, and removing medicinal cannabis.
   2. AB 527 (Wood), Chapter 618, Statutes of 2021, provided that if any cannabinoid is federally rescheduled or otherwise made a legally prescribable controlled substance, it will also be legal to prescribe under state law. AB 527 also reconciled conflicts between state and federal controlled substance schedules.
      
   3. SB 311 (Hueso), Chapter 384, Statutes of 2021, enacted Ryan’s Law to require a health care facility to allow a terminally ill patient to use medicinal cannabis in the facility.
   4. SB 305 (Hueso), of the 2019-20 Legislative Session, was similar to SB 311, but was vetoed by Governor Newsom, who stated:
      

It is inconceivable that the federal government continues to regard cannabis as having no medicinal value. The federal government’s ludicrous stance puts patients and those who care for them in an unconscionable position. Nonetheless, health facilities certified to receive payment from the federal Centers for Medicare and Medicaid Services must comply with all federal laws in order to receive federal reimbursement for the services they provide. This bill would create significant conflicts between federal and state law that cannot be taken lightly. Therefore, I begrudgingly veto this bill.

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

Date of Hearing: June 20, 2023

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

SBPCA Bill Id:SB 302

Author:(Stern) – As Amended Ver:June 12, 2023

SENATE VOTE: 39-0

SUBJECT: Compassionate Access to Medical Cannabis Act.

SUMMARY: Expands existing law requiring health facilities to permit terminally ill patients to have access to medical cannabis to also require health facilities to permit patients who are over 65 years of age and have a chronic disease, to have access to medical cannabis. Prohibits home health agencies (HHAs) from withholding care to individuals utilizing cannabis for medical purposes. Defines a chronic disease to mean a condition that lasts one or more years and requires ongoing medical attention or limits the activities of daily living, or both.

EXISTING LAW:

1. Licenses and regulates health facilities, including clinics, general acute care hospitals (GACHs), skilled nursing facilities (SNFs), congregate living health facilities (CLHFs), hospice facilities and HHAs by the Department of Public Health (DPH). [Health and Safety Code (HSC) §1200, §1250, and §1725]
2. Establishes the Compassionate Use Act (CUA) of 1996, also known as Proposition 215, which protects patients and their primary caregivers from criminal prosecution or sanction for obtaining and using marijuana for medical purposes upon the recommendation of a physician. Protects physicians who recommend marijuana to a patient for medical purposes from being punished or denied any right or privilege. States that the purpose of CUA is to ensure that seriously ill Californians have the right to obtain and use marijuana if a physician has determined that the person’s health would benefit from its use in the treatment of cancer, anorexia, AIDS, chronic pain, spasticity, glaucoma, arthritis, migraine, or any other illness for which marijuana provides relief. [HSC §11362.5]
3. Establishes the Compassionate Access to Medical Cannabis Act, or “Ryan’s Law,” to require health facilities to permit patient use of medical cannabis to support the ability of a terminally ill patient to safely use medicinal cannabis in compliance with the CUA. Defines “health facilities” as GACHs, (excluding the emergency department), SNFs, special hospitals, CLHFs, and hospice facilities. [HSC §1649 et seq.]
4. Prohibits, under Ryan’s Law, smoking or vaping as methods to use medical cannabis. [HSC §1649.2 (a)]
5. Requires a patient or primary caregiver to be responsible for acquiring, retrieving, administering, and removing medicinal cannabis. Requires medicinal cannabis to be stored securely at all times in a locked container in the patient’s room or with the patient’s primary caregiver, and prohibits health care professionals and facility staff from administering medicinal cannabis or retrieving medicinal cannabis from storage. [HSC §1649.2 (d) (e) (f)]
6. Prohibits compliance with Ryan’s Law from being a condition for obtaining, retaining, or renewing a license as a health facility. [HSC §1649.5]
7. Permits a health facility to suspend compliance with Ryan’s Law if a federal regulatory agency initiates enforcement action against a health care facility related to medical marijuana, or a federal regulatory agency otherwise provides notification to the health facility that expressly prohibits the use of medical marijuana in health care facilities. [HSC §1649.6]
8. Establishes the California Uniform Controlled Substances Act, which among other things, classifies controlled substances into five schedules according to their danger and potential for abuse, and classifies cannabis as a Schedule I controlled substance. [HSC §11000, et seq., §11054(d)(13)]
   
9. Establishes the Adult Use of Marijuana Act of 2016, also known as Proposition 64, which legalizes specified personal use and cultivation of marijuana for adults 21 years of age or older; reduces criminal penalties for specified marijuana-related offenses for adults and juveniles; and authorizes resentencing or dismissal and sealing of prior, eligible marijuana-related convictions. Includes provisions on regulation, licensing, and taxation of legalized use. [Business and Professions Code § 26000 et seq.]
   
10. Defines chronic and degenerative diseases to include those conditions that are neurological and neuromuscular in origin, including such disorders as Huntington’s disease, Friedrich’s ataxia, Joseph’s disease, and other disorders that are determined by the Department of Social Services to be similar in origin and clinical manifestation to the named disorders, and that affect adults. [HSC § 125205]
    

FISCAL EFFECT: According to the Senate Appropriations Committee, unknown costs, potentially hundreds of thousands, for DPH to administer and oversee the provisions.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, the National Council on Aging reports that nearly 95% of people over 65 have one chronic condition and nearly 80% have two or more. Patients using medicinal marijuana to treat a variety of chronic illnesses have unfettered access outside of healthcare facilities. However, elderly patients who live in medically assisted facilities are not afforded this same right. The author states that as a caregiver to his elderly stepfather who experiences chronic illness and utilizes cannabis in his treatment plan, he is struck that the only option to continue his most effective means of care is to keep him at home. As the law stands, when his needs become too great for their family’s capacity, he will no longer have access to this vital resource that dramatically elevates his quality of life until his life is nearly over. The author notes that with the passage of SB 311 (Hueso), Chapter 384, Statutes of 2021, the Legislature recognized the utility of cannabis in medical treatment. This bill simply allows the same access to more individuals who find benefit in it. The author concludes that the elderly deserve all viable and effective options to treat chronic disease in any medical setting.
   
   
   
2. BACKGROUND.
   1. Medical cannabis. Medical cannabis can be helpful in treating a variety of conditions. The specific disorders it can legally be used to treat vary from state to state. To date, it appears to be most effective for treating muscle spasms, chronic pain, and nausea. The U.S. Food and Drug Administration (FDA) recently approved a form of medical cannabis to treat severe childhood epilepsy. Marijuana comes from the Cannabis plant. In its leaves and buds are substances called cannabinoids. The plant contains more than 100 cannabinoids, but two are of particular interest for medical purposes: THC (delta-9 tetrahydrocannabinol) and CBD (cannabidiol). THC is the primary mind-altering ingredient in marijuana that makes people “high.” CBD does not trigger changes in the brain that lead to a high.

Possession of marijuana is illegal under federal law in the U.S. However, over 30 states and the District of Columbia currently have laws legalizing medical cannabis in some form, California being the first with the passage of Proposition 215 in 1996. As noted in existing law above, Californians have the right to obtain and use marijuana if a physician has determined that the person’s health would benefit from its use in the treatment of cancer, anorexia, AIDS, chronic pain, spasticity, glaucoma, arthritis, migraine, or any other illness for which marijuana provides relief.

A 2017 report from the National Academies of Science, “The Health Effects of Cannabis and Cannabinoids,” reviewed and summarized the medical literature published about medical cannabis, specifically examining its effectiveness and safety. It concluded that medical cannabis was particularly effective for easing chronic pain, especially pain caused by nerve damage. It can effectively control nausea and vomiting and is often used to manage those symptoms in people undergoing chemotherapy.

The National Institutes of Health notes that THC itself has proven medical benefits in particular formulations. The FDA has approved THC-based medications, dronabinol (Marinol^®) and nabilone (Cesamet^®), prescribed in pill form for the treatment of nausea in patients undergoing cancer chemotherapy and to stimulate appetite in patients with wasting syndrome due to AIDS.

• 1. Medical cannabis in hospitals. ACP Hospitals, a publication of the American College of Physicians, published an article in January 2017 entitled “Medical marijuana…in the hospital?” According to this article, with medical marijuana laws now in effect in more than half the country, hospitals are seeing more patients who have been certified to use the drug, and they are developing policies and practices in response. According to this article, as of May 2016, state laws in Connecticut and Maine permit the use of medical marijuana by hospitalized patients and give some state-level legal protection for clinicians who administer it. According to the ACP Hospitals article, the Minnesota Hospital Association has come up with three sample policies with three clear stances that hospitals can take on the issue: one template for hospitals that choose to prohibit medical cannabis in their facilities; a second template for hospitals that choose to allow patients to be able to continue their use of cannabis while in the hospital with self-directed therapy; and, a third template for hospitals that choose to incorporate the patient’s use of cannabis in the hospital’s medication process. The article pointed to the Mayo Clinic’s hospitals permitting use by patients registered with Minnesota’s medical marijuana program who come into the hospital with a cannabis product in its original container as dispensed by an approved cannabis patient center.
     
     As noted above, California law currently allows terminally ill patients to use medical cannabis in GACHs, SNFs, special hospitals, CLHFs, and hospice facilities. This bill expands existing law to also permit medical cannabis use by patients who are over 65 years of age and have a chronic disease, and prohibits HHAs from withholding care to individuals utilizing cannabis for medical purposes.
  2. Federal law and changing enforcement. At the federal level, marijuana is classified as a Schedule I substance under the Uniform Controlled Substances Act, where Schedule I substances are considered to have a high potential for dependency and no accepted medical use, which makes distribution of marijuana a federal offense. In October of 2009, the Obama Administration sent a memo to federal prosecutors encouraging them not to prosecute people who distribute marijuana for medical purposes in accordance with state law. In August of 2013, the U.S. Department of Justice (DOJ) provided an update to its marijuana enforcement policy in the aftermath of Colorado and Washington voting to legalize non-medical use of marijuana. This memo, known as the “Cole Memorandum,” stated that while marijuana remains illegal federally, the DOJ expects states like Colorado and Washington to create “strong, state-based enforcement efforts…and will defer the right to challenge their legalization laws at this time.” However, in January 2018, former U.S. Attorney General Sessions issued a Marijuana Enforcement Memorandum that rescinded the Cole Memorandum, and permitted federal prosecutors to decide how to prioritize enforcement of federal marijuana laws, weighing “all relevant considerations, including federal law enforcement priorities set by the Attorney General, the seriousness of the crime, the deterrent effect of criminal prosecution, and the cumulative impact of particular crimes on the community.”
     
     In remarks in front of a Senate Appropriations subcommittee hearing on April 26, 2022, Attorney General Merrick Garland stated that the DOJ will not prioritize persecuting marijuana use. While President Biden campaigned on decriminalizing marijuana, there has been no significant progress toward making marijuana legal at the federal level.
  3. Chronic disease in California. According to the California Health Care Foundation 2020 report (CHCF report), “Quality of Care: Chronic Conditions,” many Californians suffer from chronic disease. Chronic conditions such as diabetes and heart disease were the leading cause of death and disability in the United States. In 2018, high blood pressure was the most common chronic condition, affecting three in 10 adults in California. In 2018, over one in four adults in California was obese. About four in 10 Black adults in California was obese. One in three adults with Medi-Cal coverage was obese, the highest rate of any payer group. Black Californians had higher mortality rates for breast, prostate, lung, and colorectal cancer than Asian, Latino, and white Californians in 2017. The largest disparity was with prostate cancer, where Black men had mortality rates that were two times higher than the rate for Latino and white men and four times higher than the rate for Asian men.
     
     The CHCF report notes that in California, nearly 700 hospitalizations per 100,000 people were potentially preventable through effective chronic care management and access to high-quality primary care, based on a composite measure of hospital admission rates for eight chronic care conditions. The preventable hospitalization rate varied from a low of 129 in Mono County to a high of 1,341 in Butte County.

1. SUPPORT. The Society of Cannabis Clinicians (SCC), supports this bill and points to a National Council on Aging report that shows nearly 95% of people over 65 have one chronic condition and nearly 80% have two or more. SCC states that patients using medical cannabis to treat a variety of chronic illnesses have unfettered access outside of healthcare facilities, however, elderly patients who live in medically assisted facilities are not afforded this same right. These patients who suffer with pain continue to use opioids for many chronic conditions despite their limited long-term efficacy and adverse side effects. SCC also points to a 2017 UC Berkeley study that reported that 97% of a statewide sample of medicinal cannabis users agreed that they are able to decrease the amount of opiates they consume when they also use cannabis, and 81% agreed that taking cannabis by itself was more effective at treating their condition than taking opioids.
   
   California Health Coalition Advocacy supports this bill and notes that the use of medicinal cannabis has the potential to decrease dependence on opioids for the management of chronic pain, and that patients looking for alternative options for pain relief should have access to medicinal cannabis.
   
2. PREVIOUS LEGISLATION.
   1. SB 988 (Hueso), Chapter 242, Statutes of 2022, revises Ryan’s Law by repealing the requirement that health facilities comply with drug and medication requirements applicable to Schedule II, III, and IV drugs when permitting patient use of medicinal cannabis, and instead requires the patient or primary caregiver to be responsible for acquiring, retrieving, administering, and removing medicinal cannabis. Requires medicinal cannabis to be stored in a locked container in the patient’s room or with the patient’s primary caregiver, and prohibits healthcare professionals and facility staff from administering medicinal cannabis or retrieving it from storage.
   2. SB 311 (Hueso), Chapter 384, Statutes of 2021 enacts Ryan’s Law to require a health care facility to permit a terminally ill patient, defined as a prognosis of one year or less to live, to use medical cannabis within the health care facility.
   3. AB 527 (Wood), Chapter 618, Statutes of 2021, provides that if any cannabinoids are federally rescheduled or otherwise made a legally prescribable controlled substance, they shall also be legal to prescribe under state law, and reconciles conflicts between state and federal controlled substance schedules.
      
   4. SB 305 (Hueso) of 2019 was similar to SB 311, but was vetoed by Governor Newsom. In his veto message, the Governor stated that “It is inconceivable that the federal government continues to regard cannabis as having no medicinal value. The federal government’s ludicrous stance puts patients and those who care for them in an unconscionable position. Nonetheless, health facilities certified to receive payment from the federal Center for Medicare and Medicaid Services must comply with all federal laws in order to receive federal reimbursement for the services they provide. This bill would create significant conflicts between federal and state law that cannot be taken lightly. Therefore, I begrudgingly veto this bill.”
   5. SB 223 (Hill), Chapter 699, Statutes of 2019, authorizes the governing board of a school district, a county board of education, or the governing body of a charter school maintaining kindergarten or any of grades 1 to 12, to adopt a policy that allows a parent or guardian of a pupil to possess and administer non-smokeable and non-vapeable medicinal cannabis to the authorized pupil at a school site.
   6. SB 94 (Committee on Budget and Fiscal Review), Chapter 27, Statutes of 2017, establishes a single system of administration for cannabis laws in California, combining the Medical Cannabis Regulation and Safety Act with the Adult Use of Marijuana Act.
   7. AB 266 (Rob Bonta), Chapter 689, Statutes of 2015, SB 643 (McGuire), Chapter 719, Statutes of 2015, and AB 243 (Wood), Chapter 688, Statutes of 2015 was a package of bills that creates a licensing and regulatory framework for medical marijuana under the Medical Marijuana Regulation and Safety Act.

REGISTERED SUPPORT / OPPOSITION:

Support

Americans for Safe Access
California Health Coalition Advocacy
California NORML (UNREG)
Society of Cannabis Clinicians
UDW/AFSCME Local 3930

Opposition

None on file.

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

 THIRD READING  

Bill No: SB 302

Author: Stern (D), et al.

Amended: 3/30/23

Vote: 21

SENATE HEALTH COMMITTEE: 12-0, 3/29/23

AYES: Eggman, Nguyen, Glazer, Gonzalez, Grove, Hurtado, Limón, Menjivar, Roth, Rubio, Wahab, Wiener

SENATE JUDICIARY COMMITTEE: 11-0, 4/18/23

AYES: Umberg, Wilk, Allen, Ashby, Caballero, Durazo, Laird, McGuire, Min, Niello, Wiener

SENATE APPROPRIATIONS COMMITTEE: 7-0, 5/18/23

AYES: Portantino, Jones, Ashby, Bradford, Seyarto, Wahab, Wiener

SUBJECT: Compassionate Access to Medical Cannabis Act or Ryan’s Law

SOURCE: Author

DIGEST:

This bill expands existing law requiring health facilities to permit terminally ill patients to have access to their medical cannabis to also require health facilities to permit patients who are over 65 years of age and have a chronic disease to have access to their medical cannabis.

ANALYSIS:

Existing law:

1. Licenses and regulates various health facilities, including clinics, hospitals, skilled nursing facilities, intermediate care facilities, congregate living health facilities, correctional treatment facilities, and hospice facilities by the California Department of Public Health (CDPH). Licenses and regulates residential care facilities for the elderly by the Department of Social Services. [HSC §1200, §1250, and §1569]
2. Establishes the Compassionate Use Act (CUA) of 1996, also known as Proposition 215, which protects patients and their primary caregivers from criminal prosecution or sanction for obtaining and using marijuana for medical purposes upon the recommendation of a physician. Protects physicians who recommends marijuana to a patient for medical purposes from being punished or denied any right or privilege. States that the purpose of CUA is to ensure that seriously ill Californians have the right to obtain and use marijuana if a physician has determined that the person’s health would benefit from its use in the treatment of cancer, anorexia, AIDS, chronic pain, spasticity, glaucoma, arthritis, migraine, or any other illness for which marijuana provides relief. [HSC §11362.5]
3. Establishes the Compassionate Access to Medical Cannabis Act, or “Ryan’s Law,” to require health facilities to permit patient use of medical cannabis in order to support the ability of a terminally ill patient to safely use medicinal cannabis in compliance with the CUA. [HSC §1649 et seq.]
4. Requires a health facility, under Ryan’s Law, including hospitals, skilled nursing facilities, intermediate care facilities, and others, to permit patients who are terminally ill with a prognosis of life of one year or less to use medical cannabis. [HSC §1649.2]
5. Prohibits, under Ryan’s Law, smoking or vaping as methods to use medical cannabis. [HSC §1649.2 (a)]
6. Requires a patient or primary caregiver to be responsible for acquiring, retrieving, administering, and removing medicinal cannabis. Requires medicinal cannabis to be stored securely at all times in a locked container in the patient’s room or with the patient’s primary caregiver, and prohibits health care professionals and facility staff from administering medicinal cannabis or retrieving medicinal cannabis from storage. [HSC §1649.2 (d)€(f)]
7. Prohibits compliance with Ryan’s Law from being a condition for obtaining, retaining, or renewing a license as a health facility. [HSC §1649.5]
8. Permits a health facility to suspend compliance with Ryan’s Law if a federal regulatory agency initiates enforcement action against a health care facility related to medical marijuana, or a federal regulatory agency otherwise provides notification to the health facility that expressly prohibits the use of medical marijuana in health care facilities. [HSC §1649.6]
9. Establishes the California Uniform Controlled Substances Act, which among other things, classifies controlled substances into five schedules according to their danger and potential for abuse, and classifies cannabis as a Schedule I controlled substance. [HSC §11000, et seq., §11054(d)(13)]

This bill:

1. Expands Ryan’s Law, which requires health facilities to permit patients who are terminally ill to use medical cannabis, to also allow medical cannabis access to patients who are over 65 years of age and have a chronic disease.
2. Defines “chronic disease,” for purposes of this bill, as a condition that lasts one or more years and requires ongoing medical attention or limits the activities of daily living, or both.

Comments

1. Author’s statement. According to the author, the National Council on Aging reports that nearly 95% of people over 65 have one chronic condition and nearly 80% have two or more. Patients using medicinal marijuana to treat a variety of chronic illnesses have unfettered access outside of healthcare facilities. However, elderly patients who live in medically assisted facilities are not afforded this same right. As a caregiver to my elderly stepfather who experiences chronic illness and utilizes cannabis in his treatment plan, I am struck that my only option to continue his most effective means of care is to keep him at home. As the law stands, when his needs become too great for our family’s capacity, he will no longer have access to this vital resource that dramatically elevates his quality of life until his life is nearly over. With the passage of SB 311 (Hueso, Chapter 384, Statutes of 2021), we have already seen the Legislature recognize the utility of cannabis in medical treatment. This bill simply allows the same access to more individuals who find benefit in it. Our elderly deserve all viable and effective options to treat chronic disease in any medical setting.
2. Background on medical marijuana. California was the first state in the nation to allow for the medical use of marijuana with the passage of Proposition 215 in 1996. Since then, according to the National Conference of State Legislatures, 33 more states, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands have enacted similar laws. Following enactment of Proposition 215 (CUA), the Institute of Medicine issued a report in 1999 stating that scientific data indicate the “potential therapeutic value of cannabinoid drugs, primarily THC, for pain relief, control of nausea and vomiting, and appetite stimulation.” The report went on to state that the psychological effects of cannabinoids, such as anxiety reduction, sedation, and euphoria can influence their potential therapeutic value. More recently, in January 2017, the National Academies of Sciences, Engineering, and Medicine published a review of the scientific research on cannabis published since 1999, considering more than 10,000 scientific abstracts to reach nearly 100 conclusions. This review found evidence to support that patients who were treated with cannabis or cannabinoids were more likely to experience significant reductions in pain symptoms. It also found benefits for multiple sclerosis-related muscle spasms, and preventing and treating chemotherapy-induced nausea and vomiting. Along with certain benefits, the review of the science suggested cannabis is likely to increase the risk of developing schizophrenia and other psychoses, and that with greater frequency of cannabis use, there is an increased likelihood of developing problem cannabis use.
3. Background on medical marijuana in hospitals. ACP Hospitals, a publication of the American College of Physicians, published an article in January 2017 entitled “Medical marijuana…in the hospital?” According to this article, with medical marijuana laws now in effect in more than half the country, hospitals are seeing more patients who have been certified to use the drug, and they are developing policies and practices in response. According to this article, as of May 2016, state laws in Connecticut and Maine permit the use of medical marijuana by hospitalized patients and give some state-level legal protection for clinicians who administer it. However, with regard to Maine, where medical cannabis has been legal for years and even with state law permitting use in a hospital, hospitals commonly prohibit the use of the drug in their facilities. In 2015, a Maine- registered marijuana patient, hospitalized with a blood infection, tried to treat himself by rubbing an infused lotion onto his hand to relieve pain and stiffness from carpal tunnel. The hospital told the patient to remove the substance from the hospital or it would be confiscated. Elsewhere, according to the ACP Hospitals article, the Minnesota Hospital Association came up with three sample policies with three clear stances that hospitals can take on the issue: one template for hospitals that choose to prohibit medical cannabis in their facilities; a second template for hospitals that choose to allow patients to be able to continue their use of cannabis while in the hospital with self-directed therapy; and a third template for hospitals that choose to incorporate the patient’s use of cannabis in the hospital’s medication process. The article pointed to the Mayo Clinic’s hospitals permitting use by patients registered with Minnesota’s medical marijuana program who come into the hospital with a cannabis product in its original container as dispensed by an approved cannabis patient center.

Related/Prior Legislation

SB 988 (Hueso, Chapter 242, Statutes of 2022) revised Ryan’s Law by repealing the requirement that health facilities comply with drug and medication requirements applicable to Schedule II, III, and IV drugs when permitting patient use of medicinal cannabis, and instead required the patient or primary caregiver to be responsible for acquiring, retrieving, administering, and removing medicinal cannabis. Required medicinal cannabis to be stored in a locked container in the patient’s room or with the patient’s primary caregiver, and prohibited healthcare professionals and facility staff from administering medicinal cannabis or retrieving it from storage.

SB 311 (Hueso, Chapter 384, Statutes of 2021) enacted Ryan’s Law to require a health care facility to permit a terminally ill patient, defined as a prognosis of one year or less to live, to use medical cannabis within the health care facility.

SB 305 (Hueso of 2019) was similar to SB 311, but was vetoed by Governor Newsom. In his veto message, the Governor stated that “It is inconceivable that the federal government continues to regard cannabis as having no medicinal value. The federal government’s ludicrous stance puts patients and those who care for them in an unconscionable position. Nonetheless, health facilities certified to receive payment from the federal Center for Medicare and Medicaid Services must comply with all federal laws in order to receive federal reimbursement for the services they provide. This bill would create significant conflicts between federal and state law that cannot be taken lightly. Therefore, I begrudgingly veto this bill.”

SB 223 (Hill, Chapter 699, Statutes of 2019) authorized the governing board of a school district, a county board of education, or the governing body of a charter school maintaining kindergarten or any of grades 1 to 12, to adopt a policy that allows a parent or guardian of a pupil to possess and administer non-smokeable and non-vapeable medicinal cannabis to the authorized pupil at a school site.

SB 94 (Committee on Budget and Fiscal Review, Chapter 27, Statutes of 2017) established a single system of administration for cannabis laws in California, combining the Medical Cannabis Regulation and Safety Act with the Adult Use of Marijuana Act.

AB 266 (Bonta, Chapter 689, Statutes of 2015), SB 643 (McGuire, Chapter 719, Statutes of 2015), and AB 243 (Wood, Chapter 688, Statutes of 2015) was a package of bills that established a licensing and regulatory framework for medical marijuana under the Medical Marijuana Regulation and Safety Act.

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

According to the Senate Appropriations Committee, unknown costs, potentially hundreds of thousands, for CDPH to administer and oversee the provisions.

SUPPORT: (Verified 5/19/23)

California Cannabis Coalition

California Health Coalition Advocacy

California NORML

UDW/AFSCME Local 3930

Weed for Warriors

2 individuals

OPPOSITION: (Verified 5/19/23)

None received

ARGUMENTS IN SUPPORT: California Health Coalition Advocacy states in support that the use of medicinal cannabis has the potential to decrease dependence on opioids for the management of chronic pain, and that patients looking for alternative options for pain relief should have access to medicinal cannabis. California NORML states in support that a 2017 UC Berkeley Study reported that 97% of a statewide sample of medicinal cannabis users agreed that they are able to decrease the amount of opiates they consume when they also use cannabis, and 81% agreed that taking cannabis by itself was more effective at treating their condition than taking opioids. UDW/AFSCME Local 3920 states in support that according to the National Council on Aging, approximately 95% of persons over the age of 65 have one chronic illness, and nearly 80% have two or more. Outside of health care facilities, those who utilize medical marijuana to treat a range of chronic conditions have unrestricted access, but older individuals living in medically assisted institutions do not have that same luxury and have no choice but to continue the use of opioids.

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

5/20/23 12:41:16

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SENATE COMMITTEE ON APPROPRIATIONS

Senator Anthony Portantino, Chair

2023 - 2024 Regular Session

SB 302 (Stern) - Compassionate Access to Medical Cannabis Act

Bill Summary:

SB 302 would expand existing law requiring health facilities to permit terminally ill patients to have access to their medical cannabis to also require health facilities to permit patients who are over 65 years of age and have a chronic disease to have access to their medical cannabis.

Fiscal Impact:

Unknown costs, potentially hundreds of thousands, for the California Department of Public Health (CDPH) to administer and oversee the provisions.

Background:

The CDPH licenses and regulates health care facilities, including hospitals, skilled nursing facilities, and intermediate care facilities.

Current law establishes the Compassionate Access to Medical Cannabis Act, or “Ryan’s Law,” to require health facilities to permit patient use of medical cannabis in order to support the ability of a terminally ill patient to safely use medicinal cannabis. The law requires a health facility, including hospitals, skilled nursing facilities, intermediate care facilities, and others, to permit patients who are terminally ill with a prognosis of life of one year or less to use medical cannabis. Current statute permits a health facility to suspend compliance with Ryan’s Law if a federal regulatory agency initiates enforcement action against a health care facility related to medical marijuana, or a federal regulatory agency otherwise provides notification to the health facility that expressly prohibits the use of medical marijuana in health care facilities.

Proposed Law:

SB 302 would expand on Ryan’s Law, which requires health facilities to permit patients who are terminally ill to use medical cannabis, to also allow medical cannabis access to patients who are over 65 years of age and have a chronic disease. SB 302 would define “chronic disease,” for purposes of the bill, as a condition that lasts one or more years and requires ongoing medical attention or limits the activities of daily living, or both.

-- END --

SENATE JUDICIARY COMMITTEE

Senator Thomas Umberg, Chair

2023-2024 Regular Session

Bill No: SB 302 (Author:Stern)

Version: March 30, 2023

Hearing Date: April 18, 2023

Fiscal: Yes

Urgency: No

Consultant: AWM

SUBJECT

Compassionate Access to Medical Cannabis Act or Ryan’s Law

DIGEST

This bill expands existing law requiring specified health facilities to permit terminally ill patients to have access to their medical cannabis to also require those health facilities to permit patients who are over 65 years of age and have a chronic disease to have access to their medical cannabis.

EXECUTIVE SUMMARY

Medical cannabis has been legal in California since 1996. At the federal level, however, cannabis use of any sort remains illegal; and while the federal government has generally forbore from taking enforcement action against individuals and entities engaging in state-legal medical cannabis activities, the possibility of such action creates risks for industries subject to federal regulations. To address the concerns posed by one particular industry—medical facilities—the Legislature in 2022 enacted SB 311 (Hueso, Ch. 384, Stats. 2021), known as the Compassionate Access to Medical Cannabis Act, or Ryan’s Law. Ryan’s Law created a compromise framework that allows terminally ill patients to use medical marijuana in specified medical facilities without the direct participation of facility staff, provided that the patients using cannabis to comply with certain health and safety requirements.

This bill permits patients aged 65 and older with a chronic disease to use medical cannabis within the medical facilities covered by Ryan’s Law.

This bill is sponsored by the author and supported by Americans For Safe Access, California Health Coalition Advocacy, and California NORML. There is no known opposition. This bill was passed out of the Senate Health Committee with a vote of 12-0.

PROPOSED CHANGES TO THE LAW

Existing law:

1. Establishes the Compassionate Use Act (CUA) of 1996, also known as Proposition 215, which protects patients and their primary caregivers from criminal prosecution or sanction for obtaining and using marijuana for medical purposes upon the recommendation of a physician, with the goal of ensuring that seriously ill Californians have the right to obtain and use marijuana for medical purposes where the medical use is deemed appropriate and has been recommended by a physician, as specified. (Health & Saf. Code, § 11362.5.)
2. Establishes a medical marijuana program through which qualified patients may obtain identification cards to be used to obtain medical marijuana and establishes requirements for establishments that possess, cultivate, or distribute medical cannabis. (Health & Saf. Code, div. 10, ch. 6, art. 2.5, §§ 11362.7 et seq.)
3. Establishes the Compassionate Access to Medical Cannabis Act, also known as “Ryan’s Law,” which reflects the Legislative intent to support the ability of a terminally ill patient to safely use medical cannabis within specified health care facilities in compliance with state law. (Health & Saf. Code, div. 2, ch. 4.9, §§ 1649 et seq.)
4. Defines the following relevant terms for purposes of 2):
   1. A “health care facility” is a health care facility specified in specific subdivisions of Health and Safety Code section 1250, and includes a general acute hospital, a skilled nursing facility, a special hospital, a congregate living health facility, and a hospice facility; the term excludes a chemical dependency recovery hospital, a state hospital, and an emergency department of a health care facility while the patient is receiving emergency services and care. (Health & Saf. Code, § 1649.1(b).)
   2. “Medical cannabis” is cannabis or a cannabis product used in compliance with the CUA and medical marijuana program. (Health & Saf. Code, § 1649.1(c).
   3. “Patient” is an individual who is terminally ill, except a patient does not include an individual receiving emergency services and care. (Health & Saf. Code, § 1649.1(d).)
   4. “Terminally ill” is a medical condition resulting in a prognosis of life of one year or less, if the disease follows its natural course.
5. Requires a health care facility to permit patient use of medical cannabis provided that certain requirements are met, including:
   1. The facility must prohibit smoking or vaping as methods to use medical cannabis.
   2. The use of medical cannabis must be included within the patient’s medical records.
   3. The patient must provide the facility with a copy of their medical marijuana identification card.
   4. The medical cannabis must be stored securely in a locked container in the patient’s room, in a designated area, or with the primary caregiver, and can be administered only by the patient or primary caregiver; health care professionals and facility staff are prohibited from retrieving or administering the medical cannabis. (Health & Saf. Code, § 1649.2.)
6. Requires, upon the patient’s discharge, the patient or caregiver to remove all remaining medical cannabis from the premises; if the patient is unable to do so and does not have an available primary caregiver to remove the medical cannabis, the product shall be stored in a locked container until it is disposed of in accordance with the health facility’s policy. (Health & Saf. Code, § 1649.3.)
7. Establishes that a health facility is not required to provide or furnish a patient with a recommendation to use medical cannabis under the CUA. (Health & Saf. Code, § 1649.4.)
8. Authorizes the Department of Public Health to enforce Ryan’s Law, and establishes that compliance with Ryan’s Law is not a condition for obtaining, retaining, or renewing a license as a health care facility. (Health & Saf. Code, § 1649.5.)
9. Authorizes a health care facility to suspend compliance with 5) if certain federal entities take specified action against the health care facility, and clarifies that a health care facility may not refuse to comply with 5) due solely to the fact that cannabis use is prohibited under federal law. (Health & Saf. Code, § 1649.6.)

This bill:

1. Defines “chronic disease” within Ryan’s law as a condition that lasts one or more years and requires ongoing medication or limits the activities of daily living, or both.
2. Modifies the definition of “patient” within Ryan’s law to include an individual who is over 65 years of age with a chronic disease, thereby expanding the obligation of a health care facility to permit those patients to use prescription cannabis medication within those facilities under the terms of Ryan’s law.

COMMENTS

1. Author’s comment

According to the author:

The National Council on Aging reports that nearly 95% of people over 65 have one chronic condition and nearly 80% have two or more. Patients using medicinal marijuana to treat a variety of chronic illnesses have unfettered access outside of healthcare facilities. However, elderly patients who live in medically assisted facilities are not afforded this same right. As a caregiver to my elderly stepfather who experiences chronic illness and utilizes cannabis in his treatment plan, I am struck that my only option to continue his most effective means of care is to keep him at home. As the law stands, when his needs become too great for our family’s capacity, he will no longer have access to this vital resource that dramatically elevates his quality of life until his life is nearly over. With the passage of SB 311 (2021) we have already seen the Legislature recognize the utility of cannabis in medical treatment. This bill simply allows the same access to more individuals who find benefit in it. Our elderly deserve all viable and effective options to treat chronic disease in any medical setting.

2. Background on state-level cannabis laws, federal conflict concerns, and Ryan’s Law

California has permitted medical cannabis use since 1996.^[1] Adult recreational cannabis use was approved by the voters in 2016,^[2] and the Legislature subsequently enacted the Medical and Adult Use Cannabis Regulation and Safety Act (MAUCRSA) to streamline and synthesize the licensing and regulatory regimes for medical and recreational cannabis.^[3] According to the National Conference of State Legislatures, as of February 2022, 37 states, three territories, and the District of Columbia authorize cannabis for medical use.^[4]

Despite the widespread adoption of medical cannabis laws at the state level, cannabis remains a Schedule I narcotic under federal law.^[5] There has not, to date, been any widespread federal effort to crack down on medical cannabis activity that is legal at the state level. Nevertheless, the possibility of federal action against state-level medical cannabis activities causes uncertainty for many entities, particularly because the federal government’s approach to forbearance can differ from administration to administration.^[6]

Enter Ryan’s Law. While many terminally ill Californians use medical cannabis pursuant to the CUA, many medical facilities—which are subject to extensive federal regulations—were concerned that providing cannabis to patients and otherwise assisting in patients’ cannabis use would result in negative federal action, including losing federal funding and facing penalties.^[7] Ryan’s Law was adopted as a compromise: terminally ill patients in specified health facilities can self-administer or have a caretaker administer medical cannabis.^[8] Terminally ill patients using cannabis under Ryan’s Law are also responsible for the safe storage of their cannabis and must provide certain information about their medical cannabis to the facility.^[9] Although the California Hospital Association and California Association of Health Facilities remained opposed to the bill,^[10] Ryan’s Law was passed by the Senate with a vote of 36-0 and signed by the Governor.

3. This bill expands Ryan’s Law to permit cannabis use in covered medical facilities by a person aged 65 years or older with a chronic disease

This bill extends the provisions allowing terminally ill patients in specified medical facilities to use, with or without the assistance of a caretaker, medical cannabis, pursuant to the existing conditions and restrictions provided by Ryan’s Law. The analysis of the Senate Health Committee, which is incorporated here by reference, addresses the bill’s policy as it pertains to patient wellbeing, the potential risks for medical facilities, and other health-related issues. This Committee has jurisdiction over the bill because the rights conferred by the bill are extended on the basis of two classifications—age and health status—which may place this bill in a constitutional gray area.

4. This bill’s expansion of Ryan’s law to persons aged 65 or older and who have a chronic illness may present equal protection concerns

“The Fourteenth Amendment to the United States Constitution and article I, section 7, of the California constitution guarantee all persons equal protection of the law.”^[11] The principle of equal protection “of course, does not preclude the state from drawing any distinctions between different groups of individuals, but it does require that, at a minimum, persons similarly situated with respect to the legitimate purpose of the law receive like treatment.”^[12] Accordingly, “a classification must be reasonable, not arbitrary, and must rest upon some ground of difference having a fair and substantial relation to the object of the legislation, so that all persons similarly circumstanced shall be treated alike.”^[13] The classification must reflect “inherent differences in situations related to the subject-matter of the legislation.”^[14]

Generally speaking, legislative classifications—including age classifications—are “clothed in a presumption of constitutionality.”^[15] But if “the classification scheme affects a fundamental interest or right the burden shifts,” and the state must establish that it has a “[c]ompelling interest which justifies the law and then demonstrate that the distinctions drawn are [n]ecessary to further that purpose.”^[16]

Under this framework, courts have invalidated age-related classification schemes. For example, the Medical Injury Compensation Reform Act (MICRA), as amended in 1975, established a different statute of limitations for medical malpractice actions based on age: for adults, the statute of limitations tolled from the date or injury, while for minors, the statute of limitations ran for three years from the date of the wrongful act.^[17] The effect of these two provisions was to give minors a shorter window in which to bring a MICRA claim; the stated goal of this distinction was to reduce the number of “long tail” claims, thereby increasing certainty about potential liability for any given period of coverage and, theoretically, decreasing insurance costs.^[18] The California Supreme Court declined to specifically invalidate the statute of limitations provisions but opined that “it is difficult to see how discrimination against minor malpractice plaintiffs vis-à-vis adults is rationally related to this or any other ascertainable legislative goal.”^[19] Ten years later, a Court of Appeal followed the California Supreme Court’s suggestion and ruled that the classification had no relation to the statutory objective.^[20]

Here, Ryan’s Law currently allows all terminally ill persons—regardless of age—to possess and administer medically prescribed cannabis at their health care facilities, as specified. The rights granted by Ryan’s Law, as such, are contingent upon membership in a class, specifically, the class of those who are terminally ill. While this Committee did not analyze the bill that enacted Ryan’s Law, there does not appear to be any serious constitutional problem with a legislative classification based on the severity of a medical condition, particularly where, as here, the medical product in question poses federal law concerns for the health care facilities.

The classification set forth in this bill is more complex. Rather than relying solely on the medical status of the patient who has a prescription for medical cannabis, this bill allows persons aged 65 and older and who have a chronic disease to possess and administer medically prescribed cannabis at their health care facility. The classification is thus not solely aged-based—not all persons over 65 can access cannabis under this bill—nor solely condition-based—not all persons who are chronically ill can access cannabis under this bill.

According to the author, the bill’s definition of “chronic disease” was adapted from the Center for Disease Control’s (CDC) definition. The CDC defines “chronic disease” broadly; conditions that last a year or more or limit the activities of daily living include diabetes, tooth decay, and arthritis as well as cancer and heart disease.^[21] As the author notes, the National Council on Aging states that nearly 95 percent of adults aged 65 and older have a chronic condition, and nearly 80 percent have two or more chronic conditions.^[22] But chronic diseases are not unique to persons aged 65 and older; the CDC estimates that six in ten Americans overall live with at least one chronic disease.^[23] It thus does not appear that chronic diseases are so correlated with age that the classifications are functionally coterminous.

Overall, it appears that this bill treats chronically ill persons differently, not on the basis of the severity of their disease, but on their age. For example, if two cancer patients suffering the same symptoms were residing in a covered facility, and one was 66 years old and one was 63 years old, this bill would grant the 66-year-old patient the right to medical cannabis while denying the 63-year-old patient the same relief. There is no case law directly on point addressing whether this specific classification runs afoul of equal protection principles, but precedent suggests that this classification exists in a gray area.

SUPPORT

Americans For Safe Access

California Health Coalition Advocacy

California NORML

OPPOSITION

None known

RELATED LEGISLATION

Pending legislation: None known.

Prior legislation:

SB 311 (Hueso, Ch. 384, Stats. 2021) required a health care facility to permit a terminally ill patient, defined as a prognosis of one year or less to live, to use medical cannabis within the health care facility.

SB 305 (Hueso, 2019) was nearly identical to SB 311, above, but was vetoed by Governor Gavin Newsom, who stated in his veto message, “It is inconceivable that the federal government continues to regard cannabis as having no medicinal value. The federal government’s ludicrous stance puts patients and those who care for them in an unconscionable position. Nonetheless, health facilities certified to receive payment from the federal Center for Medicare and Medicaid Services must comply with all federal laws in order to receive federal reimbursement for the services they provide. This bill would create significant conflicts between federal and state law that cannot be taken lightly. Therefore, I begrudgingly veto this bill.”

PRIOR VOTES:

Senate Health Committee (Ayes 12, Noes 0)

**************

1. Compassionate Use Act (Prop. 215), as approved by voters, Gen. Elec. (Nov. 5, 1996). ↑

2. The Control, Regulate, and Tax Adult Use of Marijuana Act (Prop. 64), as approved by voters, Gen. Elec. (Nov. 8, 20216). ↑

3. SB 94 (Senate Committee on Budget and Fiscal Review, Ch. 27, Stats. 2017). ↑

4. National Conference of State Legislatures, Report, State Medical Cannabis Laws (updated Sept. 12, 2022), https://www.ncsl.org/health/state-medical-cannabis-laws. All links in this analysis are current as of April 14, 2023. ↑

5. 21 U.S.C. § 812. Drugs designated as Schedule I ostensibly have a high potential for abuse, no currently accepted medical use in treatment in the United States, and a lack of accepted safety for use of the drug or other substance under medical supervision. (Id., § 812(b)(1).) Opium and fentanyl, by contrast, are designated as Schedule II. (Id., § 812, Schedule II.) ↑

6. Compare, e.g., United States Department of Justice, Office of the Deputy Attorney General, Memorandum for All United States Attorneys: Guidance Regarding Marijuana Enforcement (Aug. 29, 2013) (federal-level cannabis enforcement priorities generally will not include state-legal cannabis activity, known as the “Cole Memo”) with Office of the Attorney General, Memorandum for All United States Attorneys: Marijuana Enforcement (Jan. 4, 2018) (rescinding the Cole Memo). ↑

7. Sen. Com. on Health, Rep. on Sen. Bill No. 311 (2021-2022 Reg. Sess.) as amended Mar. 1, 2021, pp. 5-6. ↑

8. Health & Saf. Code, § 1649.2. ↑

9. Ibid. ↑

10. Sen. Unfinished Bus. Rep. on Sen. Bill. 311 (2021-2022 Reg. Sess.) as amended Sept. 1, 2021, p. 7. ↑

11. Photias v. Doerfler (1996) 45 Cal.App.4th 1014, 1017. ↑

12. Brown v. Merlo (1973) 8 Cal.3d 855, 861 (internal quotation marks and citations omitted). ↑

13. Young v. Haines (1986) 41 Cal.3d 883, 899 (internal quotations omitted.) ↑

14. Ibid. (internal quotation marks omitted). ↑

15. People v. Olivas (1976) 17 Cal.3d 236, 251; see In re Arthur W. (1985) 171 Cal.App.3d 179, 186 (age is not a suspect classification; “ ‘[w]hile the age of each of us at any particular time is the certain result of the date of our birth, the progression through the stages of life is simply a natural process to which every one of us is subject. As a result, no member of an age group labors under any disability not encountered by every other member of society at some point in time.’ ”). ↑

16. Olivas, supra, 17 Cal.3d at p. 251. ↑

17. Photias, supra, 45 Cal.App.4th at p. 1017. ↑

18. Id. at p. 1018. ↑

19. Young, supra, 41 Cal.3d at p. 900. ↑

20. Photias, supra, 45 Cal.App.4th at p. 1020. ↑

21. Centers for Disease Control and Prevention, Health and Economic Costs of Chronic Diseases (last updated Sept. 8, 2022), https://www.cdc.gov/chronicdisease/about/costs/index.htm. ↑

22. National Council on Aging, Get the Facts on Healthy Aging (Mar. 13. 2023), https://www.ncoa.org/article/get-the-facts-on-healthy-aging. ↑

23. CDC, Living Well With a Chronic Disease (last reviewed Mar. 2, 2023), https://www.cdc.gov/chronicdisease/index.htm. ↑

SENATE COMMITTEE ON HEALTH

Senator Dr. Susan Talamantes Eggman, Chair

BILL NO: SB 302

SUBJECT: Compassionate Access to Medical Cannabis Act or Ryan’s Law

SUMMARY:

Expands existing law requiring health facilities to permit terminally ill patients to have access to their medical cannabis to also require health facilities to permit patients who are over 65 years of age and have a chronic disease to have access to their medical cannabis.

Existing law:

1. Licenses and regulates various health facilities, including clinics, hospitals, skilled nursing facilities, intermediate care facilities, congregate living health facilities, correctional treatment facilities, and hospice facilities by the California Department of Public Health (CDPH). Licenses and regulates residential care facilities for the elderly by the Department of Social Services. [HSC §1200, §1250, and §1569]
2. Establishes the Compassionate Use Act (CUA) of 1996, also known as Proposition 215, which protects patients and their primary caregivers from criminal prosecution or sanction for obtaining and using marijuana for medical purposes upon the recommendation of a physician. Protects physicians who recommends marijuana to a patient for medical purposes from being punished or denied any right or privilege. States that the purpose of CUA is to ensure that seriously ill Californians have the right to obtain and use marijuana if a physician has determined that the person’s health would benefit from its use in the treatment of cancer, anorexia, AIDS, chronic pain, spasticity, glaucoma, arthritis, migraine, or any other illness for which marijuana provides relief. [HSC §11362.5]
3. Establishes the Compassionate Access to Medical Cannabis Act, or “Ryan’s Law,” to require health facilities to permit patient use of medical cannabis in order to support the ability of a terminally ill patient to safely use medicinal cannabis in compliance with the CUA. [HSC §1649 et seq.]
4. Requires a health facility, under Ryan’s Law, including hospitals, skilled nursing facilities, intermediate care facilities, and others, to permit patients who are terminally ill with a prognosis of life of one year or less to use medical cannabis. [HSC §1649.2]
5. Prohibits, under Ryan’s Law, smoking or vaping as methods to use medical cannabis. [HSC §1649.2 (a)]
6. Requires a patient or primary caregiver to be responsible for acquiring, retrieving, administering, and removing medicinal cannabis. Requires medicinal cannabis to be stored securely at all times in a locked container in the patient’s room or with the patient’s primary caregiver, and prohibits health care professionals and facility staff from administering medicinal cannabis or retrieving medicinal cannabis from storage. [HSC §1649.2 (d)€(f)]
7. Prohibits compliance with Ryan’s Law from being a condition for obtaining, retaining, or renewing a license as a health facility. [HSC §1649.5]
8. Permits a health facility to suspend compliance with Ryan’s Law if a federal regulatory agency initiates enforcement action against a health care facility related to medical marijuana, or a federal regulatory agency otherwise provides notification to the health facility that expressly prohibits the use of medical marijuana in health care facilities. [HSC §1649.6]
9. Establishes the California Uniform Controlled Substances Act, which among other things, classifies controlled substances into five schedules according to their danger and potential for abuse, and classifies cannabis as a Schedule I controlled substance. [HSC §11000, et seq., §11054(d)(13)]

This bill:

1. Expands Ryan’s Law, which requires health facilities to permit patients who are terminally ill to use medical cannabis, to also allow medical cannabis access to patients who are over 65 years of age and have a chronic disease.
2. Defines “chronic disease,” for purposes of this bill, as a condition that lasts one or more years and requires ongoing medical attention or limits the activities of daily living, or both.

FISCAL EFFECT:

This bill has not been analyzed by a fiscal committee.

COMMENTS:

1. Author’s statement. According to the author, the National Council on Aging reports that nearly 95% of people over 65 have one chronic condition and nearly 80% have two or more. Patients using medicinal marijuana to treat a variety of chronic illnesses have unfettered access outside of healthcare facilities. However, elderly patients who live in medically assisted facilities are not afforded this same right. As a caregiver to my elderly stepfather who experiences chronic illness and utilizes cannabis in his treatment plan, I am struck that my only option to continue his most effective means of care is to keep him at home. As the law stands, when his needs become too great for our family’s capacity, he will no longer have access to this vital resource that dramatically elevates his quality of life until his life is nearly over. With the passage of SB 311 (Hueso, Chapter 384, Statutes of 2021), we have already seen the Legislature recognize the utility of cannabis in medical treatment. This bill simply allows the same access to more individuals who find benefit in it. Our elderly deserve all viable and effective options to treat chronic disease in any medical setting.
2. Background on medical marijuana. California was the first state in the nation to allow for the medical use of marijuana with the passage of Proposition 215 in 1996. Since then, according to the National Conference of State Legislatures, 33 more states, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands have enacted similar laws. Following enactment of Proposition 215 (CUA), the Institute of Medicine issued a report in 1999 stating that scientific data indicate the “potential therapeutic value of cannabinoid drugs, primarily THC, for pain relief, control of nausea and vomiting, and appetite stimulation.” The report went on to state that the psychological effects of cannabinoids, such as anxiety reduction, sedation, and euphoria can influence their potential therapeutic value. More recently, in January 2017, the National Academies of Sciences, Engineering, and Medicine published a review of the scientific research on cannabis published since 1999, considering more than 10,000 scientific abstracts to reach nearly 100 conclusions. This review found evidence to support that patients who were treated with cannabis or cannabinoids were more likely to experience significant reductions in pain symptoms. It also found benefits for multiple sclerosis-related muscle spasms, and preventing and treating chemotherapy-induced nausea and vomiting. Along with certain benefits, the review of the science suggested cannabis is likely to increase the risk of developing schizophrenia and other psychoses, and that with greater frequency of cannabis use, there is an increased likelihood of developing problem cannabis use.
3. Background on medical marijuana in hospitals. ACP Hospitals, a publication of the American College of Physicians, published an article in January 2017 entitled “Medical marijuana…in the hospital?” According to this article, with medical marijuana laws now in effect in more than half the country, hospitals are seeing more patients who have been certified to use the drug, and they are developing policies and practices in response. According to this article, as of May 2016, state laws in Connecticut and Maine permit the use of medical marijuana by hospitalized patients and give some state-level legal protection for clinicians who administer it. However, with regard to Maine, where medical cannabis has been legal for years and even with state law permitting use in a hospital, hospitals commonly prohibit the use of the drug in their facilities. In 2015, a Maine- registered marijuana patient, hospitalized with a blood infection, tried to treat himself by rubbing an infused lotion onto his hand to relieve pain and stiffness from carpal tunnel. The hospital told the patient to remove the substance from the hospital or it would be confiscated. Elsewhere, according to the ACP Hospitals article, the Minnesota Hospital Association came up with three sample policies with three clear stances that hospitals can take on the issue: one template for hospitals that choose to prohibit medical cannabis in their facilities; a second template for hospitals that choose to allow patients to be able to continue their use of cannabis while in the hospital with self-directed therapy; and a third template for hospitals that choose to incorporate the patient’s use of cannabis in the hospital’s medication process. The article pointed to the Mayo Clinic’s hospitals permitting use by patients registered with Minnesota’s medical marijuana program who come into the hospital with a cannabis product in its original container as dispensed by an approved cannabis patient center.
4. Federal marijuana law and changing enforcement approaches. At the federal level, marijuana is classified as a Schedule I substance under the Uniform Controlled Substances Act, where Schedule I substances are considered to have a high potential for dependency and no accepted medical use, which makes distribution of marijuana a federal offense. In October 2009, the Obama Administration sent a memo to federal prosecutors encouraging them not to prosecute people who distribute marijuana for medical purposes in accordance with state law. In August 2013, the U.S. Department of Justice provided an update to its marijuana enforcement policy in the aftermath of Colorado and Washington voting to legalize non-medical use of marijuana. This memo, known as the “Cole Memorandum,” stated that while marijuana remains illegal federally, the Department of Justice expects states like Colorado and Washington to create “strong, state-based enforcement efforts…and will defer the right to challenge their legalization laws at this time.” However, in January 2018, former U.S. Attorney General Sessions issued a Marijuana Enforcement Memorandum that rescinded the Cole Memorandum, and permitted federal prosecutors to decide how to prioritize enforcement of federal marijuana laws, weighing “all relevant considerations, including federal law enforcement priorities set by the Attorney General, the seriousness of the crime, the deterrent effect of criminal prosecution, and the cumulative impact of particular crimes on the community.” While President Biden campaigned on decriminalizing marijuana, there has been no significant progress toward making marijuana legal at the federal level.
5. Risk for hospitals. Even though it is legal in California, facilities have expressed concern about running afoul of federal law. According to a February 2017 article in Hospital Pharmacy, “Considerations for Hospital Policies Regarding Medical Cannabis Use,” hospitals potentially carry enormous risk for allowing cannabis use by patients because cannabis is illegal under federal law. Because they are accredited through the Center for Medicare and Medicaid Services, hospitals could be found in violation, lose federal funding, and face penalties. Clinicians are also prohibited from prescribing or providing the drug in a hospital because it is not approved by the U.S. Food and Drug Administration. Yet, hospitals in more states are asked to create cannabis policies as voters decriminalize cannabis for medical use. The Joint Commission Standard includes a policy for medications brought into the hospital by patients, which requires the hospital, before use or administration of a medication brought into the hospital by a patient, to identify the medication and visually evaluate the medication’s integrity. Additionally, the hospital is required to inform the patient if the medication brought into the hospital is not permitted. According to the article, some hospitals have considered cannabis policies that could adequately address this standard, but several questions remain, such as how the institution verifies its integrity. Finally, the article states that while many institutions may choose to continue to ban cannabis product use by their patients, there is still a question about how appropriate or comprehensive the patient care will be if a patient will be taking a different medication regimen while in the hospital versus their usual environment.
6. Double referral. This bill is double referred. Should it pass out of this committee, it will be referred to the Senate Judiciary Committee.
7. Prior legislation. SB 988 (Hueso, Chapter 242, Statutes of 2022) revised Ryan’s Law by repealing the requirement that health facilities comply with drug and medication requirements applicable to Schedule II, III, and IV drugs when permitting patient use of medicinal cannabis, and instead required the patient or primary caregiver to be responsible for acquiring, retrieving, administering, and removing medicinal cannabis. Required medicinal cannabis to be stored in a locked container in the patient’s room or with the patient’s primary caregiver, and prohibited healthcare professionals and facility staff from administering medicinal cannabis or retrieving it from storage.
   
   SB 311 (Hueso, Chapter 384, Statutes of 2021) enacted Ryan’s Law to require a health care facility to permit a terminally ill patient, defined as a prognosis of one year or less to live, to use medical cannabis within the health care facility.
   
   SB 305 (Hueso of 2019) was similar to SB 311, but was vetoed by Governor Newsom. In his veto message, the Governor stated that “It is inconceivable that the federal government continues to regard cannabis as having no medicinal value. The federal government’s ludicrous stance puts patients and those who care for them in an unconscionable position. Nonetheless, health facilities certified to receive payment from the federal Center for Medicare and Medicaid Services must comply with all federal laws in order to receive federal reimbursement for the services they provide. This bill would create significant conflicts between federal and state law that cannot be taken lightly. Therefore, I begrudgingly veto this bill.”
   
   SB 223 (Hill, Chapter 699, Statutes of 2019) authorizes the governing board of a school district, a county board of education, or the governing body of a charter school maintaining kindergarten or any of grades 1 to 12, to adopt a policy that allows a parent or guardian of a pupil to possess and administer non-smokeable and non-vapeable medicinal cannabis to the authorized pupil at a school site.
   
   SB 94 (Committee on Budget and Fiscal Review, Chapter 27, Statutes of 2017) established a single system of administration for cannabis laws in California, combining the Medical Cannabis Regulation and Safety Act with the Adult Use of Marijuana Act.
   
   AB 266 (Bonta, Chapter 689, Statutes of 2015), SB 643 (McGuire, Chapter 719, Statutes of 2015), and AB 243 (Wood, Chapter 688, Statutes of 2015) was a package of bills that established a licensing and regulatory framework for medical marijuana under the Medical Marijuana Regulation and Safety Act.
8. Support. California Health Coalition Advocacy states in support that the use of medicinal cannabis has the potential to decrease dependence on opioids for the management of chronic pain, and that patients looking for alternative options for pain relief should have access to medicinal cannabis. California NORML states in support that a 2017 UC Berkeley Study reported that 97% of a statewide sample of medicinal cannabis users agreed that they are able to decrease the amount of opiates they consume when they also use cannabis, and 81% agreed that taking cannabis by itself was more effective at treating their condition than taking opioids. UDW/AFSCME Local 3920 states in support that according to the National Council on Aging, approximately 95% of persons over the age of 65 have one chronic illness, and nearly 80% have two or more. Outside of health care facilities, those who utilize medical marijuana to treat a range of chronic conditions have unrestricted access, but older individuals living in medically assisted institutions do not have that same luxury and have no choice but to continue the use of opioids.

SUPPORT AND OPPOSITION:

Support: California Health Coalition Advocacy

California NORML

UDW/AFSCME Local 3930

Oppose: None received

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