Assembly Standing Committee on Health

You. Good afternoon. We'll go ahead and get started here now, before we begin our Health Committee here. And I guess I should bang the gavel. There we go. Now it's official. Before we begin, I'd like to say a few words. We seek to protect the rights of all who participate in the legislative process so that we can have effective of deliberation on the critical issues facing California. All witnesses will be testifying in person. We allow two main witnesses for a maximum of three minutes each.

Additional testimony will also be in person and limited to name, position and organization. If you represent one, all comments are limited to the Bill at hand. We have three bills proposed for consent for today's hearing. Any Member of the Committee may remove a Bill from consent. We have item number five, AB 483 by Mr. Muratsuchi. Item number 12, AB 365, by Ms. Aguiar-Curry. And item number 15, AB 1462 by Mr. Jim Patterson.

At this point, we do not have a quorum, so we won't be able to take any official action on any bills. And we do not have an author to present a Bill. So we'll just hang out here for a few more minutes. Thank you. Dr. Bains, would you like to present your Bill? Welcome to the Assembly Health Committee.

Thank you.

Whenever you're ready.

It's nice to be here. Awesome. Thank you. Chairman and members, I am here today to present AB 33 Fentanyl Task Force, to the Health Committee. AB 33 is the first Bill that I introduced on my very first day in office because I have been living the fentanyl crisis firsthand. As a physician and addiction specialist in Kern, County, I have seen firsthand how our efforts to combat this crisis have fallen short and allowed fentanyl to become the single deadliest drug threat in our nation's history.

There was enough fentanyl seized by the Drug Enforcement Administration last year to kill every man, woman and child in America. That's 28,000 pounds of fentanyl, representing more than 370,000,000 lethal doses. Fentanyl is increasingly being laced and cut into other drugs like heroin and cocaine to bulk them out with cheap filler in addition to its addictive properties as well, exposing people to lethal doses who do not even know they are using the drug.

All of this has led to the sobering reality that fentanyl overdose was found to be the leading cause of death for Americans between the ages of 18 and 45. In 2019 and 2020, fentanyl kills twice the number of people that die in car accidents or from gun violence. Over 150 people a day die from fentanyl in the United States, and it's now responsible for one in five youth deaths in California. We have to do better, and AB 33 is a step in that direction.

The Bill establishes the Fentanyl Addiction and Overdose Prevention Task Force, co chaired by the Attorney General and the California Surgeon General. The fentanyl crisis is a multi sector problem that needs multi sector solutions. The task force will bring experts from medicine, public health, public safety, addiction and governing backgrounds to the table to promote collaboration and informed decision making. The task force will focus on increasing access to overdose, reversing drugs, and crafting strategies to reduce the availability of illicit fentanyl.

It will work to raise public awareness about the dangers of fentanyl and identify better ways to connect people with substance use disorder treatment and recovery support. Working with law enforcement and public health officials, the task force can monitor drug distribution and develop strategies to prevent the use, manufacture and distribution of illicit fentanyl.

By focusing on strategies to reduce the availability of fentanyl, while working to improve access to treatment and increasing public awareness, the task force can help to reduce the devastating impact that fentanyl is having on our communities. Importantly, the task force will tell us in Legislature what tools we need to make available to effectively combat the crisis. They will tell us what's working, what's not, and where we need to go from here.

In my experience, I've held the hand of too many children who just found out that their mom or dad has died of an overdose. And even more heartbreaking, I've held the hand of parents whose child passed away after being exposed to a lethal dose of fentanyl. Please join me in supporting AB 33 to help stamp out this crisis, hold those responsible accountable, and get people the help they need to stay alive.

With me today in support of the Bill is Sarah Bridge on behalf of the Association of California Healthcare Districts.

Thank you, Mr. Chair Members. Sarah Bridge on behalf of the Association of California Healthcare Districts here in proud support of AB 33. Healthcare districts, or ACHD, represents the 77 healthcare districts throughout the State of California. Healthcare districts provide life saving care to millions of Californians and service 44 counties in the state. Healthcare districts are on the front lines of care in their communities. For the safety of their patients, providers and first responders, California must make a concerted effort to systematically address this epidemic.

Fentanyl is a major contributor to drug overdose death. It's highly volatile and puts providers and first responders at continued risk. Fentanyl is a synthetic opioid that is 50 times stronger than heroin and 100 times stronger than morphine. The California Department of Public Health reported that based on preliminary 2021 data, that 6843 deaths were related to opioid overdose in California alone. Of those, 5722 of these deaths were related to fentanyl. This is unacceptable.

AB 33, as the Assemblymember mentioned, will establish a task force cochaired by the Attorney General and the California Surgeon General to develop informed strategies to tackle one of the most pressing public health crises. The task force will include experts from the medical community, public health, public safety, addiction and governing backgrounds to the table to promote collaboration and informed decision making.

The objective of this body will be to identify strategies to increase access to opioid antagonists, improve substance use disorder treatment recovery and support, and reduce the availability of illicit fentanyl. The task force will develop strategies to increase public awareness about the dangers of fentanyl as we connect people with substance use disorder treatment and recovery support. California is a leader in healthcare. It's time we become a leader in addressing the fentanyl crisis. AB 33 will save lives.

It's for this reason that ACHD is in strong support and urges your aye vote. Thank you.

Thank you very much. Are there others in support of this Bill? Just your name, obviously. Support, position and any organization if you represent one.

Thank you, Mr. Chair, members of the Committee, Brandon Marchy, with the California Medical Association in support.

Thank you.

Hello. Leah Barros, on behalf of California Hospital Association, in support.

Thank you.

Connie Delgado, on behalf of the California Emergency Nurses Association, in support. Letter coming.

Thank you.

Hello Mason Vega. I'm here on behalf of the California Partnership for Health, the Central Valley Health Network and Health Care LA, in support.

Thank you.

Good afternoon, Mr. Chair. And members, Elizabeth Espinosa, here on behalf of the county Health Executives Association of California in support, are requesting a modest amendment to please include local health departments in this effort. And we have submitted a letter and is reflected in the analysis. Thank you.

Thank you.

Good afternoon, Mr. Chair. Members Ryan Sherman, with the Riverside Sheriff's Association, in support. Also in support, the police officer associations of the cities of Claremont, Corona, Pomona, Palos Verdes, Newport Beach, Upland, Santa Ana, Burbank, Marietta, Arcadia, Riverside, Fullerton, Culver City, and the deputy sheriff Association of Monterey County and Placer county, all in support. Thank you.

Thank you very much. Is there anyone else? Seeing no one. Is there any opposition to the Bill? Seeing no one. We'll bring it back to the Committee. Questions or comments? Ms. Vice Chair, Ms. Waldron, really quickly.

Thank you, Mr. Chair. I'm very happy, Assembly Member Bains, that you've brought this forward, very important Bill. I remember back in 2000, when I was on the City Council, San Diego created the opioid task force, and they brought in law enforcement, as well as health entities and parents and everyone else that was dealing with the issue. And it was my first exposure to what was going on with the opioid crisis. And I was a City Council Member. I had not even heard about it.

And as a parent, it was very informative. And then from there on, we went on to raise awareness everywhere about it. And now, with fentanyl, once again, we're dealing with it, and we need to do something about it. We keep talking about it. So getting the data, getting people together, is very important, and I'd love to be added as a co-author as the Bill moves forward, when there's an opportunity. Thank you.

And I'd too like to thank you, Dr. Bains, for bringing this Bill forward. I think, as with our Vice Chair, we've sat here through many hearings talking about the opioid crisis, and now we've moved on to something synthetic, like this horrible drug, and the consequences of that.

I, too, would like to consider being added as a co-author here, and I hope that if this task force is actually put into play, that it can work at a speed that is not usually typical of our task force, because I think the urgency of this is very significant. So the Bill does enjoy a do pass recommendation. We are so far short of a quorum, but we will get to a quorum at some point.

And at this point, I'd like to give you the opportunity to close, if you'd like.

Sure. Thank you again, Committee Members, thank you for meeting with me. Thank you for the comments as well. For me working on the front lines of fentanyl for the past six years, going back for my community of Kern, this is something that is very near and dear to not just my community, but very many people in California. So I respectfully request an aye vote.

Thank you very much. Seeing northern authors present. Ms. Quirksilva, you are present, so please come forward before us item number 10, AB 1477.

Thank you, and good afternoon, Mr. Chair. Is this one?

No. There we go.

Thank you and good afternoon, Mr. Chair, and Members. First, I want to thank the Committee consultant for working with my office and accept the proposed Committee amendments. California's addiction problem is a statewide crisis. From 2020 to 2021, we have seen a 45% increase in drug related deaths, and more than half of them being a result of synthetic opioids, including fentanyl.

AB 1477 approaches this crisis by making sure our state's nonprofit providers and programs are able to keep their doors open in order to provide the critical services our communities need. During the 2022 budget process, the Department of Healthcare Services requested an increase to provider fees by 63%. However, the fees were denied by the Legislature because we were concerned that would exasperate the shortage of vital treatment programs, increase costs to our programs that are currently struggling, and prevent new programs from opening in our communities.

AB 1477 establishes a moratorium on fee increases for the licensing and certifying of nonprofit residential treatment facilities and programs that provide addiction treatments to medical beneficiaries to the rate that was last published in 2022. Additionally, AB 1477 requires the rate to remain in effect until 2031 or until deaths related to any oepoid overdose reported by the California overdose surveillance dashboard have declined by 50%, whichever is first. Lastly, once fees may be increased, they are capped at no more than 10% per year.

I do have some witnesses, but let me check to see if they're here. Since I jumped ahead, we did have Ms. Sherry Daley, Vice President of Government Affairs. Yeah, I think we'll have to do without our witnesses, if that's okay with that.

I'm not Sherry, but if I was that.

Well, then, please come up. Dr. Leandra Clark Harvey.

No, that is not Dr. Leandra Carvey.

Dr. BJ Davis.

All right. Well, welcome.

How do I get in?

We often ask that. It's a trick we like to see if you can figure out.

Thank you.

Welcome.

Thank you.

We have someone else coming quickly here. All right. Two witnesses. Perfect. Quickly. Since we jumped ahead of the line. Catch your breath. That's okay.

I apologize, Chair.

That's okay. That's no problem.

Good afternoon, Honorable Chair and Members Sherry Daley with the California Consortium of Addiction programs and professionals, representing over 20,000 addiction focused professionals, more than 100 treatment programs, 350 recovery residences, and thousands of people living in recovery throughout California. Today, I would like to draw your attention to addiction treatment capacity issues our state now faces in attempting to bring down opioid and stimulant deaths and to address homeless attributable to untreated substance use disorder.

Simply put, we do not have enough treatment beds, outpatient services or recovery housing to meet our needs. In May of 2021, the Department of Healthcare Services reported a budget, sub to Budget Subcommittees that there were 17,904 residential treatment beds. Today, there are 18,129, a mere increase of 215 new beds statewide. While we face historic increases in cases, the shortage in beds is acute and chronic. In the public safety net system 56 of 58 counties are not meeting network adequacy requirements for medical enrollees.

The shortage of beds is so critical that one of California's largest counties is now stepping down clients from detox who have met need for inpatient treatment to unregulated sober living. This is the only alternative to not returning these people to the streets. There are not beds for them. To understand why AB 1477 is necessary, let me describe what our inpatient programs look like. Over 50% of our residential inventory is provided by six bed facilities.

Many of these providers are small, what we would call mom and pop facilities run by highly committed people who are dedicated to saving lives and in many cases, paying it forward. To say these operators run on slim margins is an understatement. They do not have large staffs and resources to spread the workload needed to adjust to caling changes now underway.

We are hearing directly from many of them that the pace of change and lack of resources to assist them could make these changes seriously consider retiring their businesses. CCAP has deep concerns that a huge increase in licensing and certification fees could be the proverbial star that prompts straw that prompts them to leave the system.

AB 1477 was carefully crafted to delay fee increases to allow our programs to recover from pandemic setbacks, encourage expansion to meet the explosive growth in demand, and deliver a message from policymakers that our contributions to reducing deaths and homelessness are valued. It also provides a mechanism for gradually raising fees to prevent an undue shock to the system in the future, while allowing the Department the time it needs to widen the pool of regulated programs proposed in its trailer. Bill, I urge your support of this Bill. Thank you.

Thank you. Please go ahead. Introduce.

Good afternoon Honorable Chair, Members. I am Dr. BJ Davis. I've been in the substance misuse and co-occurring mental health treatment field for 23 years. I'm currently the Executive Director for Sacramento Recovery House Incorporated, one of the few residential programs here in Sacramento. We provide a broad menu of services for residential treatment facilities. I'm also a Professor in the doctoral clinical psychology program at Alliant University.

I'm 25 years clean and I was invited to do a TED talk regarding my own recovery story a couple of years ago. So I know a little something about systems treatment and recovery. I'm here today to share with you the many challenges our alcohol and drug treatment programs are facing so that you will consider supporting a temporary freeze. This Bill on increasing our licensing fees. Before the COVID pandemic began, our programs faced major challenges in managing resources to remain financially solvent.

MediCal reimbursement has a long history of being Low when compared to private pay rates. This resulted in providers like myself having to operate with very small margins, often borrowing from Peter to pay Paul, but still managing to provide the much needed treatment to the populations we serve, which are poor and marginalized, the populations that are at higher risk and with the least resources. When the pandemic began, things got worse. People with addiction were afraid to come in due to possibility infection.

Families prioritized finances and safety over getting their loved ones into treatment. There was also continuous outbreaks among staff, which caused temporary closure of programs and limited services for those who stayed open due to diminished staffing for those exposed to infection and those who were isolating or recovering from the illness. Since we are only reimbursed for services delivered, there was an immediate impact on our financial stability. This impact threatened the entire treatment system, which you've just heard.

To alleviate the economic impact of the pandemic, fees for certification and licensure were waived. This helped many programs make ends meet during this precarious time. Unfortunately, this appears to not have been true waivers because now we're being asked to pay it back at increased amounts. When you look at what's going on, what was just set up here, the remedy is actually going to hurt, because if the fees go up, then organizations that operate at margins won't be able to pay them and keep up with it.

There's also the recovering from the pandemic, increased cost for counselors, and so. If. You increase the cost of the fees, you're going to decrease the programs. And if you decrease the programs, you're going to impact treatment, which was what was talked about here and the previous person talked about. I want to close because I only have 30 seconds with. We just had a young man, 19 years old, that died here in Sacramento. He was on a waitlist for two months because he couldn't get into treatment. He got into treatment finally after intake. He had smuggled in some fentanyl.

He overdosed while in treatment after intake, and I believe that happened because he couldn't get into treatment when he needed it. I really think this Bill is about saving lives, and I think this is a step the Legislature can do in that direction.

Thank you very much. Others in support? Just your name and position or name organization. If you represent one.

Tara Gimbo Eastman with the Steinberg Institute, in support.

Okay, thank you. Anyone else? No one. Is there opposition to the Bill? No one will bring it back to the Committee. I will note because the author did accept the amendments. Amendments include that fees for. We've stricken the word nonprofit, so this would apply to all treatment facilities. And we've also said the fees increases shall continue until licensing certifications are self sufficient. In no instance may a single year increase be more than 15%. And you've accepted those amendments?

Yeah. Okay. All right, just for clarification, do you have any questions or comments? So no questions or comments. Would you like to close?

We ask for an aye vote.

Okay. We don't have a quorum yet, so as when we do, we'll ask for a motion. It does enjoy a dupast recommendation, so. Thank you. Thank you, Members. Next, Ms Petrie-Norris.

Okay. Ms. Petrie Norris, you have AB 90 whenever you're ready.

All right, well, thank you, Mr. Chair, and Members. Happy to be here today to present AB 90, which will expand access to contraceptive care for women across California. This is a simple bill to close a gap in coverage in California's family planning program for low income women. Currently, when a patient is in the hospital receiving postpartum or gynecological care, they are actually ineligible for an inpatient long acting contraceptive device.

Instead, they have to receive it as an outpatient procedure, which we know is less effective because follow up rates for outpatient procedures are unfortunately low. This bill simply closes that gap and makes sure that if a patient wishes to receive a contraceptive device, they can do so while they are in the hospital. Proud to stand with a wonderful coalition of partners who are working with me on this bill and would now like to introduce Dr. Jewel Brown and Dr. Shiva Yazdani, please.

Thank you. Please go ahead when you're ready.

Hi. Of course. Thank you, everybody, so much for having us here today. I'm Dr. Jewel Brown. I am an obstetrician and gynecologist and a Member of the American College of OBGYNs who is sponsoring this bill and represent them as well. And we're here today in support of AB 90. This would expand the Family PACT Program to cover contraceptive devices in the hospital setting. In our practice, we take care of many patients who could benefit from increased access to contraception while receiving timesensitive services in the hospital.

I would like to tell you about one of those patients. I'll call her Carla. Carla is a 33 year old mother of two who was recently referred to me for an abortion. She lives near Redding but was unable to get the care she needed close to home because of the clinic's limited capacity. She doesn't have a car, so depends on help from others for transportation. She even had to reschedule the date her first visit with us due to her ride falling through.

As a single mom organizing child care was also a big challenge for her. When she was finally able to make it to Sacramento, she strongly desired to start a highly effective method of birth control as soon as possible. After her abortion procedure. She felt like the hormonal IUD was the right choice for her and wished to have it placed immediately after the procedure while she was asleep in the operating room. Unfortunately, her insurance coverage of restricted Medi Cal was limited to pregnancy care.

I had to tell her that even though it was medically appropriate to do so, I was not able to place the IUD after her procedure because she lacked coverage. Outside of pregnancy Carla qualifies for Fam PACT and was counseled.

We could place an IUD for her in clinic, but that Fam PACT could not cover the device placement in the hospital setting because of how hard it was for Carla to get to Sacramento for abortion, she declined to make a follow up appointment with us and decided to be seen instead by a clinic closer to home. Even today, I'm not sure if she was ever able to make it to that appointment and receive the care that she deserved.

Even though California leads the county in protecting access to reproductive health care, there are still people like Carla who are getting left behind. This bill would close an important gap and allow patients access to contraceptive devices if desired, while getting time sensitive care in the hospital setting. For this reason, I urge to vote in support of AB 90. Thank you all so much.

Thank you. Please.

I support AB 90 as well. We've seen a lot of patients similar to Carla's story, and I fully support as well.

Okay, great. Thank you. Others in support of the bill, please come forward. Just your name and organization if you represent one.

Linda Nguy with Western Center on Law and Poverty in support.

Thank you.

Molly Robson with Planned Parenthood Affiliates of California in support.

Thank you.

Erin Evans on behalf of NARAL Pro Choice California, as well as the California Nurse-Midwives Association, both in support.

Thank you.

Brandon Marchy with the California Medical Association in support.

Thank you. Anyone else? Seeing no one, is there opposition to the bill? Seeing no opposition to the bill, bring it back to the Committee. Questions or comments? Any questions? Dr. Weber.

Good afternoon, Assembly Member and Fellow OB-GYNs. Thank you so much for presenting this bill. I do have a couple of questions. First off, just at the beginning, when we're talking about traditional postpartum period, that's after someone has delivered, and they usually do have insurance so they can get a lark placed at that point. So I think probably what you're referring most to is if someone has had a termination of pregnancy and may not qualify under that specific guidelines.

The other question that I have for you is in the bill, I don't see that it is specific to a person who's just recently terminated a pregnancy. I've seen that it's actually just opening up Family PACT and Lark placement to anyone who's inpatient. Is that correct?

That's correct. It's not just restricted to post termination, it's for patients that are falling in that Family PACT coverage that can't get Lark placement in the inpatient setting to make sure that they don't have to only get those Lark placements in the outpatient setting.

Right. Exactly. That's what I read. And do we know how much funds we have within the Family PACT system and how much we're currently using on an annual basis, how much we as providers charge the California Family PACT system?

Let us follow up with you. Let's follow back up with you.

Sure. Ryan Spencer, through the Chair.

Sorry. Please go ahead.

Ryan Spencer, on behalf of American College of OBGYNs, last year's budget had about $370,000,000 appropriated for the Family PACT. It's like 280 of that federal funds, about 80 million and some change. We do have a budget request that the Assemblyman did submit this year.

Really a placeholder. We don't believe this would be a large expense to the Family PACT. We're talking about very rare cases. But for those cases when they do occur, we want to make sure that they have access to these support and services. Thank you.

Thank you. Yes. If I could get that information about how much we actually charged or billed for those services through the Family PACT to see how much of that money that we're actually using, that would be great. Thank you.

There is also a difference in the amount of cost for inpatient procedures versus things that are done on an outpatient because you have your hospital facility fees and all of these other things that are attached when you do something within the hospital setting. And so I just want to make sure that we're not drawing down on funds for patients that need this on an outpatient setting.

And since this bill does expand it to not just those who are post termination, it's really to anyone who chooses to get a lark and qualify would qualify for Family PACT on the outside. We don't really know how broad we're expanding this to. Right.

So I think it's important to know how much we have allocated, how much we're using, and whether or not we have the leeway to be this broad or if we want to kind of narrow it to a more specific subgroup, such as our post termination patients, and not just particularly any female who is inpatient.

Yes, and thank you for those points and for those questions and certainly want to make sure that we understand the financial implications of this.

I think that will obviously come out in some of the appropriations analysis, but I think we can certainly do some of that work now and do some of those calculations, and we'll certainly share that with your office as well.

Any other questions? I guess I would just as a follow up, I assume that there is. I shouldn't assume anything. There is data on the number of people, or is this on the presumption of anecdotal evidence? Sorry, is there data, do we know.

To demonstrate that this is an unmet need?

Yeah. And how many people do we have any idea?

We do see usually on average, about two to three patients a month that kind of fall into this loophole. So the issue that we're facing, it just doesn't seem right that for some patients we can offer as a service and others we can't. And often the ones that we're not able to offer as a service are already ones that have such hard obstacles to obtain the care and see us in clinic.

So, again, we are really lucky that Fam PACT can cover these procedures and outpatient, but the ideal setting for a lot of these women is to have it at the time of their procedure. So we do commonly have to deny about a couple of patients a month due to the specific loophole in the system.

And just in terms of, I think, the scale of the potential unmet need, we do know that up to 40% of individuals don't attend a postpartum visit, and 40% to 75% of individuals who say they plan to use an IUD postpartum don't end up obtaining it. And we also know that many private insurers do cover this as an inpatient service. But it's low income women who are being excluded and whose care is potentially being compromised as a result.

I'm particularly sensitive to travel distances and challenges of getting to appointments. I was just trying to get my arms around the scale of it. Did you have another question, Dr. Weber?

Yeah, I think just to your point, though, because, again, what you're focusing on are post termination patients, which is not what the bill specifies. This bill specifies any inpatient that desires a Lark or contraception. So those numbers could potentially be higher than what you're saying or what their particular thing?

Yes. And perhaps we should then amend the bill to specify that. I think I didn't.

Because is your concern that someone goes in for like a, I don't know, knee replacement and then says, while I'm at it, I'm going to get this done?

The way the bill is written is anyone inpatient? So whether or not they're having a knee replacement, whether or not they're there for a psychotic break, it's really any inpatient. I couldn't specifically find an area that honed in on gynecologic care or post termination.

So if that's the intent, in order to also get really to the numbers, then you probably need to kind of hone in.

And that is certainly the intent. And I think perhaps we didn't anticipate that.

Yes, we were making a presumption that this would be happening in a certain context, but we can certainly add that specification so that there's not, I guess, confusion or kind of unintended expansion.

Because I think your witnesses can attest that you will get called paged from any service to come and deal with gynecologic issues for inpatients. So it's not just those that are admitted to us.

Got it. Great. Thank you for. I'm always grateful for your lived experience and the way that we can leverage that to shape better policy in this committee. Thank you.

So just for clarification, should you choose to further look at amendments, you aren't doing it today. Okay, thank just. That was a statement. Any other questions or comments? Seeing none. We'll bring it back to you. Ms. Petrie-Norris. Sorry. Hang on. We do have a question by Ms. Waldron.

Dr. Weber brought up an interesting point, because we always talk about access to care and getting people in and streamlining and things. It may not necessarily be a bad thing if you're in for another procedure to get that done. At the same time, if it's difficult to get to a provider, I don't know. I guess as you look at the bill, figure out what's the most efficient for the patient.

And I appreciate what Dr. Weber is saying because it makes a lot of sense.

And I think what we have seen is that the unmet need that has been identified is certainly within the context of gynecological care and postpartum care.

Yeah, that's where we're facing it. We're not routinely, or I think, ever placing somebody coming in for a non gynecological issue with these devices. We do sometimes see people that are, like cancer patients, for instance, that need effective contraception during their chemotherapy, and we might be consulted to see them. And sometimes they do fall in that gap, or they would be best served to have a device placed in the hospital. And sometimes they do fall into this in between, depending on their insurance coverage.

So there are certain situations outside of abortion and postpartum care, but for us, particularly, where we're seeing the strongest problems is for these people that are coming all over California to our clinic just because of the resources we have for abortion care and not being able to come back for that device placement and being left without effective contraception because of distances.

Okay, anyone else? We don't have a quorum, so we can't take a vote, but would you like to close Ms. Petrie-Norris?

Thank you, Mr. Chair and Committee Members, for the robust discussion and engagement and would respectfully ask for an aye vote at the appropriate time. Thank you.

Thank you very much for bringing it forward, and when we have a quorum, we'll ask for a motion. Thank you.

Cheers.

Ms. Wilson. Whenever you're ready. You have before us AB 228.

Thank you, Mr. Chair. Good afternoon, Members. I am pleased to present AB 228, the Infant Formula Stockpile Bill. AB 228 would require the California Department of Public Health to create a program that creates a strategic stockpile of baby formula that could be tapped to ease future shortages. In 2022, the United States experienced a severe shortage of infant formula as a result of the 2021-2022 global supply chain crisis. It was compounded by a large-scale product recall.

Even as recent as this month, it is reported by the Guardian and many other publications that families still face issues finding formula, particularly parents of color and families within rural communities. The import restrictions and market concentration has also exacerbated this issue. As a result, many California parents were met with the unimaginable plight of not having enough food for their babies. Unlike other food products, infant formula often does not have an available and acceptable substitute as a source of nutrition for those who rely on it.

For these reasons, in 2022, the Food and Drug Administration Commissioner Robert Califf recommended that lawmakers consider an initiative to have a stockpile of infant formula that could be tapped to ease future shortages that may arise. This bill is modeled after Health and Safety Code 131021 which required the Department to stockpile personal protective equipment and will operate in a similar manner. The Department will also establish guidelines for procurement, management, and distribution of infant formula from the Department under advisement from the Infant Formula Advisory Committee.

They will take into account various types of infant formula, including specialty formula that may be required during a shortage, the shelf life of each type of infant formula and how to restock and distribute to ensure they are compliant with expiration dates, the funding that would be required for the state to establish and maintain a stockpile of infant formula, and the amount and type of formula that would be required to meet shortages, particularly for families that are enrolled in California programs, including, but not limited to, WIC.

My office has had several conversations with groups across California to get their input on this bill and I hope to address a few of their concerns now. We have had an ongoing conversations with the Breastfeeding Coalition as they are concerned about the exclusion of breastfeeding individuals. However, while we always support all efforts to feed infants, our bill aims to specifically address formula. We invite the Coalition to work with us in future years on the legislation they are interested in.

With me today are Evelyn Sarkis, a mother who experienced firsthand how devastating this shortage was, and Meron Agonafer from the Black Health Network to discuss how this shortage impacted a historically underserved community.

Thank you. Please go ahead.

Good afternoon. Thank you, Mr. Chair and Members of the Committee for the opportunity to speak here today. My name is Evelyn Sarkis, and I am the proud mother of Esme Rose Sarkis, who was born on June 8th, 2022, in Orange, California. While having a newborn baby will create a variety of challenges, having a daughter during the height of the formula shortage was especially difficult.

I had prepared and hoped to breastfeed my baby, but I quickly came to learn that that would not be an option for her. My little one did not take well to my breast milk and became very ill with reflux and colic. Only a very specific formula that was very difficult to find became her source of nutrition and the only formula that she could keep down.

Going from one grocery store to another and seeing empty shelf after empty shelf while I left my little one at home and I myself was recovering from a C-section created stress, anxiety, and was an extremely frustrating and scary situation. Mothers such as myself were forced to scour stores from surrounding cities, find online groups, and rely on family members to do the same for us.

While I was blessed to have resources to help me get through the shortage, it is my hope that California will implement policies that will prevent mothers of newborns from having to experience this nightmare. This is why I am proud to be here today in support of Assembly Bill 228, which will create a formula stockpile to help prevent the impacts of future shortages. Thank you again for the opportunity to speak here today, and I respectfully ask for your support on this bill.

Thank you very much. Please go ahead.

Chairman Wood and Members, my name is Meron Agonafer. I am the Policy and Legislative Affair Manager with the California Black Health Network. CBHN is a statewide organization dedicated to advancing health equity for all African Americans and Black immigrants. CBHN strongly urge your support of AB 228, Dr. Akilah Weber, Assembly Member Lori Wilson, and Dr. Jasmeet Bains. The bill requires the California Department of Public Health and the Office of Emergency Services to establish an infant formula stockpile.

The baby formula shortage impacted Black and many low-income mothers. According to the Centers for Disease Control and Prevention, fewer than 74.1 percent of Black infants are breastfed, lower than all other groups. According to the CDC report, unsupportive work policies and lack of parental leave was cited as one of the major factors for Black and low-income mothers to stop breastfeeding early. Many Black and other minority mothers don't have the luxury of staying at home or the work flexibility to breastfeed their infants.

This is due to socioeconomic factors. As a mother, I stayed at home to breastfeed my son. It was costly but delightful experience that may not be possible for many mothers who look like me. AB 228 would implement the 2022 FDA Commission's recommendation for lawmakers to consider legislation to have a stockpile of infant formula. This bill would also establish the Infant Formula Advisory Committee.

It would create guidelines for developing and implementing the program to ensure that infant formula will be available and distributed to disadvantaged communities in case of shortage. On behalf of millions of low-income families in California, I urge you to support AB 228. Thank you for your time.

Thank you very much. Others in support of the bill? Just your name and organization if you represent one.

Michelle Teran-Woolfork with the California Commission on the Status of Women and Girls, in strong support of AB 228. Thank you to the author for bringing this forward.

Thank you.

Mr. Chairman, Members, Awet Kidane, representing the Children's Hospital Association of California; have the pleasure of supporting this bill, and thank you to the author.

Thank you.

Nora Lynn, on behalf of Children Now, in support.

Thank you.

Good afternoon. Janice O'Malley with the American Federation of State, County, Municipal Employees, in support.

Thank you.

Hello. Matt Lege with SEIU California, in support.

Thank you.

Jessica Hay with the California School Employees Association, in support.

Thank you. Anyone else in support? Seeing no one, is there opposition to the bill? Seeing no one, we'll bring back to the Committee for questions or comments. Any questions? Ms. Aguiar-Curry.

Thank you for bringing the bill forward, but I do have a couple of really easy questions, I hope. Formula has an expiration date on it and there's a bill that's roaming around this building on expired, sell-by--what do we do with the expired formula and is there a way that we can make sure it gets distributed early on so we don't have that issue? A family may not be scared a little bit about getting that out.

Absolutely. That is part of the plan is to have a process by which the formula is distributed prior to the expiration date with the incorporation, including WIC and food banks, and the state already provides contributions of that level to across those networks currently, and so they would then instead of purchasing those, would get this through the stockpile. Purchasing separately would get them through the stockpile.

And can you clarify for me what does stockpile mean to you in this bill?

Stockpile is the ability to have a certain level of product on hand in case of an emergency, and that would be set by, in cooperation with the Department of Public Health as well as the Infant Advisory Commission.

Thank you very much.

Anyone else? Mr. Patterson?

Yeah, I just wanted to make comment that I have a baby born in February of 2021, and now she's a two-year-old, sometimes a monster, but we went through this issue where it was hard to find formula, and if possible, if this moves on, I'd like to be added as co-author.

Absolutely. Thank you for that. And just to note, I said Infant Advisory Committee, Infant Formula Advisory Committee, and thank you, Assembly Member Patterson, for wanting to be signed on as a co-author. And I'm so appreciative of Dr. Bains and Dr. Weber, who signed on as principal co-authors very early, and appreciate their wisdom in crafting this bill.

I very much appreciate that. We're going to stop for a second and call the roll as I sit here and envision an Infant Advisory Committee. Secretary, please call the roll.

[Roll Call].

We have a quorum. That's a good thing. And just a question to you, Ms. Wilson--very much appreciate you bringing the bill forward--so do you envision that the stockpile would be used--we've had a number of emergencies here in the state right now, I think of particularly the area around the Pajaro River where 1,700, 1,800 people evacuated--is that part of the vision of the stockpile or is it more when there is a shortage of formula or is it both?

It's actually both. So I believe when you have a stockpile, it is for emergency purposes, and it could be the emergency caused by a shortage or it could be by a natural disaster or something of that sort, and we would like it to be regionally-based, so that way you can deploy as needed for places where it's very specific like the flood, where you needed food, and you could be able to provide that for babies.

Great. Okay. Thank you very much. I appreciate that clarification. The bill does enjoy a do pass recommendation. Would you like to close?

I would. I would like to thank my witnesses, Evelyn Sarkis, who also brought her daughter Esme here today from Southern California, as well as Meron Agonafer and as well as the principal co-authors, and to the Members of the Committee, I thank you, and respectfully ask for your aye vote.

Thank you very much. Madam Secretary. Oh, we don't have a motion. That's a good point. So now we do. A motion by Ms. Waldron; second by Ms. Aguiar-Curry. Motion is 'do pass to Appropriations.' Madam Secretary, please call the roll.

[Roll Call].

You have eight votes, bill is out of Committee, we'll leave the roll open for others to add on. Thank you very much, all of you. Before we go to the next bill, we'll just want to do our consent calendar, Mr. Gipson, and then you're up, okay?

So is there a motion for the consent calendar? I'm sorry. I heard 'so moved' by Ms. Aguiar-Curry. Second by Ms. Boerner Horvath. The consent calendar includes Item Number Five, which is AB 483 by Mr. Muratsuchi, Item Number 12: AB 365 by Ms. Aguiar-Curry, Item Number 15: AB 1462 by Mr. Jim Patterson. Madam Secretary, please call the roll on the consent calendar.

[Roll Call].

Consent calendar has eight votes, so that is-- We'll leave the roll open for others to add on. Mr. Gipson, you have before us AB 632, whenever you're ready, sir.

Thank you very much, Chairman Wood and also Vice Chair Waldron and Committee Members. Thank you for allowing me to present-- Thank you very much-- to present Assembly Bill 632, which seeks to prohibit cost sharing for prostate screening for insurance enrollees who are either 55 or at least 40 years of age considering height risk by their health care provider. Prostate cancer is the second most common cancer in America, affecting one in every eight men.

And I appreciate the motion that was made and I'm just going to cut right through it. This bill is absolutely important for me because when you look at the statistics, African Americans are at a higher rate of developing prostate cancer, with the demographics being 60% more likely to develop prostate cancer than any other race. And I want to just skip down to my next paragraph. The first degree of a person who could potentially contract prostate cancer is from a father or first degree relative.

Why fall in that category? I fall in the category of being African American. I fall in the percent. And my father passed away from prostate cancer. We must do everything that we can to remove the barriers of costs in this particular area, especially because this is a treatable and preventable disease. And so here to hear their testimony and their stories are witnesses in support of this bill 632. I want to first introduce Kourtney, who was self introduced. She is with ZERO Prostate Cancer, Pacific Northwest Chapter Director, and also Ryan, who was self introduced, whose father seven years ago passed from prostate cancer.

Good afternoon, Chair and Members. I'm Kourtney Brandt. I'm the local chapter Director for ZERO Prostate Cancer. And I'm here in support of AB 632. ZERO is the leading national nonprofit with the mission to end prostate cancer and help all who are impacted. In California, we operate 17 support groups to help men and their loved ones and have six run walks to build the prostate cancer community.

We also support efforts like this one to ensure that no one fails to receive the prostate cancer screening they need because of cost. A man is diagnosed with prostate cancer every two minutes. In this three minute testimony, that's two diagnoses. In California, there will be 26,970 new cases of prostate cancer and over 4000 men will die. Prostate cancer doesn't have to be a death sentence. Diagnosed early, almost all men survive for at least five years.

For men diagnosed in the later stages, only about 30% survive for five years. Prostate cancer doesn't operate on a level playing field. Those with a first degree relative with prostate cancer have about twice the risk of prostate cancer compared to the general population. Black men are 1.7 times as likely to be diagnosed with prostate cancer and more than twice as likely to die of the disease. Those who have served in our military are also twice as likely to be diagnosed with prostate cancer.

For many individuals, even what we might think of as a small copay can be a reason not to be screened. Eliminating cost sharing makes it easier for men at high risk to be screened, diagnosed early, and to survive this disease. Importantly, eliminating cost sharing simply removes a barrier ensuring that a man and his doctor are free to make the medical choice that is right for him based on his personal medical history, his risk factors, and his values.

AB 632 allows the doctor and patient together to make the right medical decision, free from unnecessary barriers between a man and a future, free from prostate cancer. Thank you, Assemblymember Gipson, for your leadership on this issue and to the Chair and members of the Committee for your time and consideration.

Thank you. Please go ahead.

Good afternoon, Chair and members of the Health Committee, thank you for hearing this bill. And I thank Assembly Member Gibson for sponsoring this bill. This bill is important to me. My name is Ryan Pessah, and as the Assemblymember mentioned, I lost my dad seven years ago to prostate cancer. I think my dad would still be here alive and well if he was diagnosed early and had treatment early.

And what this bill would do is remove the barriers so that more people can get screened for prostate cancer. I believe early screening, and often screening is the key to keep our grandfathers, our fathers, our uncles, our brothers, our nephews alive. A lot of men that I talk to, I do a lot of advocacy in the Sacramento community, reaching out and educating people about prostate cancer. And when I talk with them about prostate cancer, a lot of people are scared. There's some scared to get tested.

And I think just a copay or a deductible is just another barrier for them to just say no. Why would I want to get screened or tested? Because I have to pay money. So just by removing this barrier, this financial barrier would help increase folks'ability to get tested often and early and receive treatment. So I appreciate the Members who offered a motion, a second to pass this bill. This bill is very important to me. Thank you.

Thank you very much. Others in support, just your name and organization if you represent one, please.

Chair and Members, Autumn Ogden-Smith with the American Cancer Society Cancer Action Network, also in strong support.

Thank you.

Good afternoon, Chair and Members. Jose Torres with Health Access California, in strong support as well.

Thank you.

Good afternoon. Linda Nguy with Western Center on Law and Poverty, in support.

Thank you.

Good afternoon. Alex Khan with the California Chronic Care Coalition, in strong support.

Thank you. Anyone else? Seeing no one, is there opposition to the bill? Seeing no one, we'll bring it back to the Committee for questions or comments. Questions or comments? Ms. Waldron?

Thank you, Mr. Chair. Just really quickly, I'm sorry for your loss. I, too, lost my dad to prostate cancer as well as my father in law. So it is something that, if I believe had been diagnosed earlier, would have made a difference. So thank you for bringing this bill.

Thank you. Anyone else? Dr. Weber.

Thank you, Assemblymember Gipson for this bill. And thank you all so much for being here to provide testimony and your stories. And I'm sorry to hear about your father. I think one of probably the main issue with prostate cancer and the lack of early screening is more education and not so much coverage. When you look at the CHIRP analysis, 97% of people who would benefit from this already have coverage with no cost sharing.

So there's only a small percentage of those that actually do have that cost sharing. And so I am looking forward to seeing what other bills that you bring forward in the future to really tackle what I think the issue is, which is more the education and the encouragement of men to go and get this simple blood test or--

I know people don't like the digital rectal exams, but I think that is really what is the barrier to earlier detection of this cancer, which a lot of money has been put towards prostate cancer treatment. So, like you said, if it's caught early, they have a very high likelihood of survival. So I think the barrier is more so education and not so much cost.

I will be supporting this, but I look forward to what else you bring in the future to help on that end, because I think that's really where we can start to see some improvement in detecting this very early on. So thank you.

Thank you. Anyone else? Bring it back to you, Mr. Gipson. The bill does enjoy a do pass recommendation. Would you like to close?

Yes, real quick. I want to meet that challenge that my colleague has extended to me. And stay tuned. I will be bringing another bill that rises that expectation. I respectfully ask for an aye vote, as has been articulated by my witnesses, as well as my own personal story, early detection, cost sharing, tearing down those barriers, but also education. I concede to that, and we'll do work in this space continuously. Thank you very much.

Thank you very much. We do have a motion by Mr. Flora, second by Mr. Rodriguez, I believe. Motion is due pass to Appropriations. Madam Secretary, please call the roll.

[Roll call]

Your bill has eight votes. It's out. We'll leave the roll open for others to add on. Thank you very much, Mr. Gipson. Dr. Weber, would you like to present? We don't have other witnesses, so please. Dr. Weber has AB 317.

With specified requirements apps are now authorized to perform patient assessments, order and interpret drug therapy related test, participate in the evaluation or management of diseases and health conditions in collaboration with other healthcare providers, independently initiate and provide life saving HIV prevention medication, perform tests for COVID or other respiratory illnesses, sexually transmitted infections, tests for strep throat, urinary tract infections, among other services.

And although pharmacists now do much more than just dispense drugs, they are only currently getting paid for dispensing drugs, not for the clinical work that we have now asked them to do.

AB 317 requires a healthcare service plan that offers coverage for a service within the scope of practice of a pharmacist to pay or reimburse the cost of services performed by a pharmacist at an in network pharmacy or by a pharmacist at an out of work pharmacy if the healthcare service plan or insurer has an out of network pharmacy benefit. In 2015, Washington became the first state to provide the ability to Bill for patient care services within the scope of practice of pharmacists.

California now has the opportunity to do the same. This Bill has no opposition. AB 317 is sponsored by the California Pharmacist Association, and I am joined today by Michelle Reeves as well as Clint Hopkins, owner of Pucci's Pharmacy.

Please go ahead.

Thank you, Mr. Chair Committee. If we learned anything from the pandemic, it is that our healthcare system is fragile. Providers and facilities were stretched beyond capacity. Pharmacists have the authority to help physicians manage patients chronic illnesses and provide preventive care. However, health insurance companies have not yet recognized them as healthcare providers. Therefore, their ability to provide these services is limited. By treating pharmacists as other healthcare providers, AB 317 will enable them to provide and Bill for patient care services.

This will increase access to care, and we respectfully request your aye vote.

Thank you.

Thank you. Mr. Chair, I'm Dr. Clint Hopkins, pharmacist and CEO of Pucci's Pharmacy, which has been part of the Sacramento community since 1930. My pharmacy has been focused on the health and wellness of Sacramento county residents for over 93 years. We know our patients and our family members by name, many of whom work in these government buildings and can speak truth to the challenges in accessing health care in their own communities.

Community pharmacists continue to be the most accessible healthcare provider, 88.9% of Americans live within 5 miles of a pharmacy. We have more interactions on an annual basis with patients than any other provider. California has more than 6,243 community pharmacies where patients interact with their pharmacists daily California is facing a healthcare provider shortages, or I'm sorry, California is facing healthcare provider shortages and pharmacists are highly educated healthcare professionals who are positioned to relieve the strain on our healthcare system.

Community pharmacies exist in both urban and rural areas throughout our state and provide services to all demographics, ages, races, and ethnicities. During interactions in the communities in which we exist, pharmacists can identify acute patient illnesses as well as needs related to the patient's existing health conditions, which can be addressed and resolved by the pharmacist during the patient's routine visit. Pharmacists were given authority to independently order and interpret tests and to initiate and provide specific medications under SB 493, signed into law by Governor Brown in 2013.

We collaborate with physicians in our communities to keep them abreast of the testing performed, results and therapies initiated, modified, or discontinued. While SB 493 propelled California's pharmacists to provider status, it did not adequately address the matter of payment for these services. Due to this lack of payment, most pharmacies, including both locally owned small businesses like mine and large chain pharmacies, have not implemented programs to provide Californians with the greater access to services which was intended by us before 93.

No provider can afford to work for free or provide testing without reimbursement, and most patients are unwilling or unable to provide for these services out of pocket, nor should they have to. They pay for their healthcare benefits and they should be able to utilize them even in their community pharmacy. Expanding access does not increase cost. It prevents patients from suffering continued illness, returns them to health, preventing further spread of illness, and prevents more costly sequile, including hospital admission, morbidity, and mortality.

Now is the time to strengthen California's position on expanding healthcare access to all persons by affording pharmacists the recognition to Bill commercial health plans for patient care that they are already authorized by statute to provide. Commercial health insurance plans are not going to do this on their own because it is the right thing to do or they already would have done it. We must legislate them to recognize pharmacists in the same way they recognize other providers such as physicians, nurse practitioners, and physician assistants.

I respectfully request your support for this important healthcare access Bill.

Thank you. Thank you very much. Others in support? Just your name and organization. Please.

Nicette Short, on behalf of Loma Linda University Health in support.

Thank you. Ryan Elaine on behalf of the California Community Pharmacy Coalition in support. Thank you.

Thank you.

Alex Khan, California Chronic Care Coalition in strong support.

Thank you. Is there opposition to the Bill? Please come on up.

Thank you, Mr. Chair Members. Jedd Hampton with the California Association of Health plans. We currently do not have a position on AB 317. We do have some clarifying questions that we are working with the author's office and the sponsors on to get some more clarity around operational implementation issues. So we look forward to having those conversations or continuing those conversations with the author's office and the sponsors moving forward.

Okay, thank you very much. We'll bring it back to the Committee for questions or comments. Mr. Patterson?

Thank you. I just have a question about how this would work. If a pharmacist, their charge is more than maybe whatever is in the contracted health plan, what does the health plan have to pay for a particular service?

So we in California have already given pharmacists the authority to do more than just dispense drugs. So you yourself may have gone to a pharmacist and you got your flu shot or your COVID shot, or you have a medication that is new when you're having to go through extensive counseling for that. All of that is time that the pharmacist is having to provide, just like your physician or your nurse practitioner would provide if you did it in a clinic.

And so what they're asking for and what they should be getting is reimbursement for their services. You get paid for your time, as they should as well.

Yes. Thank you. Because when all the, you know I look at my health bills, right? And let's say I get a service that costs $200, but the plan only pay, the contractual agreement is $100. But let's say a particular pharmacist charges, they want the $200, not the $100. How does that get ironed out with this Bill?

So that would be ironed out the same way that the health plans have ironed out with the physicians that you see, or your dental plans get ironed out by the dentists that you see. They would iron all of that out. So this would be no different than your medical plan or your dental plan. The only difference is that now your pharmacist would get covered for their services that they're providing you as well.

Thanks.

Any other questions? I'm sorry. Okay. I saw you looking. I thought maybe I missed something there, Dr. Weber. So. No, appreciate. I want to say thank you, and I appreciate you bringing this Bill forward. I agree completely with you. I think if you're providing the service, you deserve to be compensated for it and I also recognize that if you're not going to be compensated for the service, you're not likely to provide it. So there is a huge disservice to patients who could benefit from that.

We're seeing, I think, more and more, as we have challenges with providers. Providers know that pharmacists can provide certain services, and so they're often recommending that their patients get a flu shot there if that's easier for them to do, or some other vaccination, if that's easier for them to do. And you as a pharmacist, are taking time doing something that you don't do 100% of the time. It takes a little bit longer sometimes to do that because you don't do it on a regular basis.

You deserve to be compensated for that. So I'm glad you brought this Bill forward. I'm more than happy to support it. Love to be added as a co-author, if you'll allow me, and I hope it passes. I think it's way overdue. So, Dr. Weber, would you like to close?

Yes. Thank you. Chair and Committee, I think you closed off very well for me with this particular Bill. We have asked pharmacists to do more, and yet we are not paying them to do more. We not only have asked them to help with our vaccines, in my scope of practice and OB-GYNs, we're now allowing them to do things in the world of contraception. I know how much time it takes to counsel someone when they're starting on a birth control pill, and I am compensated for that.

And so if a pharmacist is going to start doing that, he or she should be compensated for that as well. And on that note, I would respectfully ask for an aye vote on AB 317.

Thank you, Dr. Weber. We have a motion from Ms. Aguiar-Curry, a second by Mr. Rodriguez. A motion is do pass to appropriations. Madam Secretary, please call the roll.

[Roll Call]

Thank you.

Your bill has nine votes. It's out. We'll allow others to add on when the time comes. All right, Mr. Berman, we'll allow you, since time is ticking. Mr. Berman, you have AB 948. Motion by Mr. Flora, second by Ms. Waldron.

Thank you for your patience, Mr. Chair. And I note the bill is currently partisan, but I assume soon to be bipartisan support for the bill. So I'll be very quick.

Since 2017, Californians have been protected from rising prescription drug costs with a $250 copay cap for a 30 day supply of medication. But that consumer protection is set to expire next year. AB 948 would make the existing copay cap permanent. Before this consumer protection was signed into law, Californians with serious and chronic conditions were particularly vulnerable to high out of pocket costs, which were often thousands of dollars.

Please join me in supporting AB 948 to ensure that Californians can access the medication that they need and focus on their health, not whether they can afford their prescription. Respectfully ask for an aye vote. And I'm joined by Marguerite Casillas, a volunteer with the National Multiple Sclerosis Society, and Katie Van Deynze, policy and legislative advocate with Health Access California.

Okay, please go ahead.

Hi, Chairman Wood, Committee Members. My name is Marguerite Casillas. I am a volunteer with the National Multiple Sclerosis Society and I have been living with MS since 2003. With MS, it's critical to start medication as early as possible and to take it consistently. MS medications are expensive, but they are powerful. They help to reduce relapses and to delay the progression of disability.

Before the copay cap, many people were forced to pay their entire annual out of pocket maximum in the very first month of the year, which is thousands of dollars before insurance would cover any of the cost. That's a significant cost for most people and out of reach for many. Without a copay cap, people may skip or delay taking their medication.

In a recent national survey by the MS Society, 40% of people with MS reported that they had altered their use of their medication due to cost, either delaying or skipping treatment. And this can lead to progression of disability and ultimately the inability to work. People with MS and other chronic conditions depend on the copay cap to keep their cost reasonable so that they can afford their medications and stay healthy.

AB 948 will give those of us with serious illnesses peace of mind when it comes to paying for our essential medications. Thank you.

Thank you. Please go ahead.

Good afternoon, Mr. Chair and Members. I'm Katie Van Deynze, policy and legislative advocate with Health Access California, the sponsor of AB 948. Health Access California sponsored AB 339 by Assemblymember Rich Gordon back in 2015 that set the $250 copay cap for a 30 day prescription and established the standards for tiers within the drug formulary, among other important consumer protections.

As we just heard from Ms. Casillas, before AB 339 consumers could pay up to the $6,000 that out of pocket maximum for a single prescription in January. With this copay cap, we've seen over these years that this helps consumers keep their prescription drug costs affordable. And with prices going up, we've seen more and more consumers hitting that $250 cap, meaning that more consumers are relying on this consumer protection to keep their costs down.

I respectfully ask for aye vote on AB 948 to make these important consumer protections permanent. Thank you.

Thank you very much. Others in support of the bill, just your name and organization. If you represent one, please.

Mr. Chair, Members of the Committee. Brandon Marchy with the California Medical Association, in support.

Thank you.

Good afternoon. Linda Nguy with Western Center on Law and Poverty, in support.

Thank you.

Mr. Chair, Members. Tim Madden, representing the California Society of Plastic Surgeons, the California Chapter of the American College of Cardiology and the California Rheumatology Alliance in support.

Thank you.

Good afternoon. Rebecca Marcus on behalf of CALPIRG, in support.

Thank you.

Jessica Hay with the California School Employees Association, in support.

Thank you.

Alex Khan with the California Chronic Care Coalition, in support.

Thank you.

Good afternoon. James Michael Agpalo with the American Federation of State County Municipal Employees, in strong support. Thank you.

Ryan Spencer on behalf of the Crohn's and Colitis foundation, in support.

Anyone else? I thought I saw someone making a beeline for that microphone there, but apparently not. Is there opposition to the bill? Seeing none. We'll bring it back to the Committee for questions or comments. Any questions or comments? We have a motion by Mr. Flora, second by Ms. Waldron. Appreciate you bringing the bill forward. And that's actually refreshing to hear the name Rich Gordon, who I remember when this bill came forward and was happy to support it then.

So with that, would you like to close, Mr. Berman?

Any bill that was initially authored by the officiant of my wedding is a good bill.

It's a good man. Was that your close? Okay. All right. Thank you. Motion is due pass to Appropriations. Madam Secretary, please call the roll.

[Roll call]

8-0. Your bill is out. We'll leave the roll open for others to add on. Mr. Gabriel. Whenever you're ready, sir.

Thank you very much, Mr. Chair and Members. I am pleased today to present AB 29, which will create the California Voluntary Do Not Sell List. This bill provides those battling suicidal ideation and struggling with mental illness option to protect themselves by temporary limiting their ability to purchase firearms during a time of crisis. There is strong evidence that shows that access to firearms increases your risk of suicide. Indeed, suicides make up over half of firearm deaths in California, and more than one-third of all suicides in California are by firearm.

This decision is preventable. Studies have found that individuals, especially those diagnosed with mental health issues, are willing to add their name to a Do Not Sell List if they have an option. Indeed, Voluntary Do Not Sell Lists have been successfully passed and are now operating in Virginia, Washington State, and Utah. Comprehensively addressing the gun violence epidemic in our country means ending gun suicides, too. AB 29 will help resolve this critical public health issue that has already taken the lives of far too many.

This bill is supported by a coalition of gun violence and public health organizations, including Moms Demand Action, Everytown for Gun Safety, and the Brady Campaign. And with me today to testify in support is Paul Yoder, on behalf of our sponsor, the California State Association of Psychiatrists. Thank you, and respectfully request your aye vote.

Thank you very much. Please go ahead.

Mr. Chairman and Members, Paul Yoder, on behalf of the California State Association of Psychiatrists, sponsor the bill. I'll keep it short. This bill will, in fact, save lives, not just people who might kill themselves, people who might kill others before they kill themselves. There's a lot of process in the bill.

You can not only get on the list, you can get off the list, and there's a very clear process for that. We do have a cooling-off period in California, but CSAP still believes that this bill absolutely will save lives. Appreciate the analysis by your consultant. It's incredibly thorough. Appreciate all the statistics that were listed. I'd ask for an aye vote. Happy to answer any questions.

Thank you very much. Others in support?

Tara Gamboa-Eastman with the Steinberg Institute, in support.

Thank you.

Rebecca Marcus, on behalf of the Brady Campaign, in support.

Thank you.

Danny Offer with Everytown for Gun Safety, in support.

Thank you. Is there opposition to the bill? Seeing none. Bring it back to the Committee for questions or comments. We have a motion by Ms. Aguiar-Curry, a second by Ms. Boerner Horvath. Any questions or comments? Dr. Weber.

Good afternoon. This is a much-needed bill, especially--I'm looking at the health component since we're in the Health Committee--but being able to provide this information to patients when they are inpatient, on the right medications, in the right state of mind, giving them the opportunity at that time is so critical. This bill is definitely needed, and I would really appreciate it if you added me as a co-author.

Would be honored to do so. Thank you, Assembly Member.

Thank you. Mr. Rodriguez, question?

Question--thank the author for bringing this bill forward--I just had a question regarding protections. What are protections in there that somebody can't just put somebody's name on there because I know your residence, your date of birth, that there's protections that it's only there intended for that person only?

Yeah. Thank you. It's a great question, and that's something that we worked with on the Public Safety Committee on to make sure that there would be appropriate protections there, both for people to make sure that folks could be added to list, but also could be taken off and make sure that there would be a system that was established. We've had conversations with the Attorney General's Office about that. Obviously, there's a public safety component, but also due process component to doing that, so we wanted to make sure that we did that in the right way.

Thank you.

Mr. Flora.

Just a fault, thank you for bringing this. I like the bill, but what is the procedure to get off the list?

So the idea here that we've negotiated with folks is that basically you can request at any point to be removed from the list. There's a period of time that it takes to process that, but then you will be removed from the list.

Okay. So it's almost as easy to get off the list as it was to get on it, with the exception of the timeframe.

Correct. Correct. And the idea here is that this is an entirely voluntary thing, right, and so this is for somebody who may worry that they know because maybe they have a mental health diagnosis or something else, that they're worried about harming themselves or potentially harming others, give an opportunity, as Dr. Weber said, for medical professionals, family members to encourage folks to put themselves on the list, but ultimately, it's an entirely voluntary thing, and that's why you've seen it done in red and in blue states.

Thanks.

Thank you very much. Anyone else? Mr. Patterson?

Yeah, I've seen this kind of method is used in the gambling world for problem gambling, and it's been pretty successful at stopping people with gambling addiction from gambling. So I think it's a very interesting bill. I do have just some concerns about just how this, obviously--bureaucracy will handle this and if somebody accidentally sells a firearm when they shouldn't, but I think I like where this has gone, so thank you for bringing it.

Thank you. Anyone else? I like the bill. Enjoys a do pass recommendation. I'd like to be added as a co-author if you'd have me at some point. And would you like to close? We do have a motion and a second.

Thank you, Dr. Wood. We'd be honored to have you as a co-author as well. Just to say to Dr. Weber's point, part of this is we've often thought about gun violence as a public safety issue, but it is also changing the frame a little bit to think about it as a public health crisis. And suicide is obviously such a big part of the public health--the gun violence deaths we have here in the State of California. We think we've come up with a good and thoughtful voluntary way to get at that and save lives, and so with that, would respectfully request an aye vote.

Thank you very much. I believe the motion was by Ms. Aguiar-Curry and second by Ms. Boerner Horvath? Is that correct? Okay. All right. I just momentarily lost that. I usually write it down. So, motion is 'do pass to Appropriations.' Madam Secretary, please call the roll.

[Roll Call].

Your bill has eight votes. It's out. We'll leave the roll open for others to add on. Thank you.

Mr. Lackey.

Okay. Mr. Lackey, are you prepared to present AB 1202?

Good afternoon and thank you for this opportunity to present AB 1202. I want to thank the Committee for their work and especially on the suggest amendments which we will be accepting in 2022. The State Auditor's office found that the Department of Health Care Services, or DHCS, had not taken sufficient steps to ensure that children and new expecting parents enrolled in MediCal in their managed care plans were receiving sufficient access to preventive care and medical services.

In the report, the Cal State Auditor found that DHCS is providing less than half of the children on MediCal with prevention services, which means an average of 2.9 million children are missing some of these essential services during particularly crucial developmental periods in their lives.

There are a number of factors identified as to why we're letting our children down, including a lack of outreach by DHCS to make families aware of the services available to them as MediCal beneficiaries, as well as problems with an insufficient amount of providers geographically to ensure that MediCal managed care plan beneficiaries are able to receive care from a primary care provider who is reasonably close by. Big problem in my district because I have a very spread out rural desert area.

These time and distance standards typically require a beneficiary travel of no more than 10 or 30 minutes to a primary care appointment location. If these standards are not being met by a managed care plan provider network, an exception must be granted by DHCS. In reviewing this process, the state auditors report found that DHCs approved nearly 10,500 exceptions related to pediatric services in fiscal year 2021.

This Bill will require DHCS to work with its managed care plans to identify the number of providers needed to ensure adequate and equitable access to MediCal services. To conduct this analysis, managed care plans will collect and provide data DHCS on what services are being received by MediCal beneficiaries and where coverage gaps exist across different age and socioeconomic groups. This is an important step forward, effectively addressing provider shortages by providing necessary information and data in order to make strategic investments in the future.

I have Andrea Riviera here with me on behalf of I'm sorry, Rivera. Not Riviera, Rivera. I apologize with me today on behalf of the California Pan Ethnic Health network to provide testimony.

Good afternoon, chair and Members. Andrea Rivera on behalf of the California Pan Ethnic Health Network I'd like to start off by stating that CPEN is pleased to support AB 1202 by Assembly Member Lackey, which is sponsored by the Children's Partnership, who unfortunately could not be here today. So I will be focusing my remarks on the reasons why CPEN supports this Bill.

AB 1202 would require the Department of Healthcare Services to conduct an analysis, and this analysis would help to identify the number of MediCal providers that are needed in order to ensure adequate access for children's healthcare services. This analysis would be completed through compliance by MediCal managed care plans, and it would take into account time and distance standards as well as appointment time standards established under existing law.

California is home to nearly 9 million children and of those children, over half, which is approximately 5.5 million, receive medical care through MediCal. In 2019, the California State Auditor determined that millions of children do not receive adequate preventative care and services which they are entitled to through MediCal. In fact, California ranks 40th among all states in providing preventative health care services to children.

In a follow up report from the State Auditor last year, it was determined that less than 50% of children enrolled in MediCal have received the required preventative services that would help ensure that they live healthier and more productive lives. With the passage of AB 1202, the state would be able to identify where more MediCal providers are needed and request additional funding from the Legislature so that we can increase the number of providers in those identified areas. As determined by the Auditor's report,

One key reason that children do not receive preventative services in many parts of this state is due to the lack of access of providers. AB 1202 would ensure the Legislature has a roadmap and can properly identify where to fill those potential investments and fulfill these gaps in communities in need. It is for these reasons that CPEN is proud to support AB 1202. Thank you.

Thank you. Are there other witnesses in support? Name, organization? Seeing none. Any witnesses in opposition? Seeing none. We'll bring it back to the Committee for questions, comments.

Anybody? No? Okay. We'll allow the author to close if you would like, Mr. Lackey.

Well, hopefully you listened to the data. It was a little dry. But I'm telling you, it's a very important bill, and there's a lot of children that need to be recognized and deserve the improved service is that this bill will point out. And so I hope to get your aye vote.

Thank you. We do have a motion for Mr. Arambula-- Dr. Arambula, a second by Assemblyman Rodriguez. Due pass as amended to Appropriations. Madam Secretary, please call the roll.

[Roll call]

8-0. Your bill is out. Thank you. Okay, next up, Assemblywoman Schiavo, we have AB 1208, item number nine.

Good afternoon, Madam Chair and Members. Thank you so much. We are happy to present AB 1208 to you today, and I appreciate the work of the Committee staff, and I'm happy to accept the Committee's amendments. The Bill requires Covered California to provide state funded cost sharing assistance to silver plan enrollees to reduce deductibles and copays for low and middle income enrollees for as long as the federal premium subsidies continue.

Almost 60% of Californians reported feeling worried about the out of pocket costs when utilizing their health insurance. That's actually a higher percentage than people worrying about the cost of housing, utilities or groceries. And so this results in delayed care or no care for many of those in need, especially for those low income families. This measure helps provide additional assistance to those families that may have to choose between paying their rent or healthcare deductibles.

Joining me today is Diana Douglas, Director of Policy and Advocacy for Health Access. And Andrea Rivera from California Pan Ethnic Health Network would love to give them an opportunity to present on the Bill as well.

Thank you. You may go ahead.

Good afternoon, Madam Chair and Members of the Committee. My name is Diana Douglas. On behalf of Health Access California, the statewide Healthcare Consumer Advocacy Coalition. We are pleased to sponsor AB 1208, which will dramatically reduce the burden of cost sharing for Covered California enrollees. Thanks to significant premium assistance, first provided by the state and then by the Federal Government, more Californians than ever are enrolled in our Covered California marketplace, and with monthly premiums that are more affordable than ever.

However, even with coverage, rising deductibles and copays keep care out of reach for many. A recent survey of Covered California enrollees specifically found that 48% delayed or skipped care due to high out of pocket costs. This is unsurprising, given deductibles often amount to several months of wages.

AB 1208 will require Covered California to annually update their cost sharing affordability design and provide cost sharing assistance for as long as the federal premium subsidies continue at the current generosity while the burden of cost sharing escalates year after year. Meanwhile, as a result of our state's individual mandate penalty, California continues to generate over 350 million by penalizing those who are uninsured. With about the same amount of investment,

what we could do is eliminate deductibles for all enrollees in silver plans, up to about 600% of the federal poverty level. So somebody making about 75,000 per year and we could also significantly reduce the copays they're paying. With AB 1208, the state would make good on its commitments to affordable health care and ensure that nobody with coverage in our marketplace is forced to skip care due to costs. We are proud to sponsor AB 1208 and ask respectfully for your aye vote.

Good afternoon, Chair and Members of the Committee, Andrea Rivera on behalf of the California Pan Ethnic Health Network. As a statewide multicultural health advocacy organization, we are pleased to support AB 1208, which will provide essential affordability assistance for low and middle income Californians who are eligible to purchase healthcare coverage through Covered California. California has made great strides to expand healthcare coverage for communities of color.

Yet despite these gains, the costs associated with Covered California's health plan options such as copays and deductibles, are increasing at a faster rate than the cost of living in this state. As these costs continue to rise, communities of color are forced to choose between paying for their health care or providing for their families and loved ones.

Last month, CalMatters shared the story of an individual, Brian Iv in Orange County, who described the challenges he faces every day as he is forced to choose between paying for health coverage and finding ways to make other ends meet. Brian suffers from chronic pain due to a lifetime of working manual labor jobs and suffering from previous workplace injuries. He often treats the pain with home remedies and traditional Cambodian healing practices because visiting the doctor is too expensive.

Brian was a longtime Covered California silver plan enrollee, and visiting the primary care doctor cost nearly $50 per visit. Each time Brian picked up prescription medication, that was an additional ten to fifteen dollars. These costs significantly add up, especially for someone who is living paycheck to paycheck and has to figure out how to pay rent and other bills with a very tight budget.

Unfortunately, Brian's story is not unique, and many BIPOC Californians opt to skip or delay care simply due to lack of subsidies and financial assistance available to. The California Healthcare Foundation released its annual health policy survey and found that half of Californians reported skipping care in the past 12 months due to skyrocketing costs. People who are black or LatinX are more likely to skip or delay care than those who are white or Asian.

And of those who skipped care have stated that their condition got worse as a result. AB 1208 will ensure that our state establishes a responsibility to provide subsidy support for communities in need during a time when many Californians are desperately in need of health care. As the state begins to unwind the public health emergency, we must ensure critical safety net support is expanded within Covered California so that community Members do not continue to forego health care due to cost burdens. Thank you.

Thank you. Are there other witnesses in support? Name, organization, position, only.

Madam Vice Chair, Brandon Marchy with the California Medical Association in support.

Hi, Robert Boykin with the California Association of Health Plans, in support.

Good afternoon. Vice Chair and Members, James Michael Agpalo with the American Federation of State, County and Municipal Employees in strong support. Thank you.

Thank you. Any other witnesses in support? Seeing none. Any testimony in opposition? Seeing none. We'll bring it back to the Committee for comments, questions, anything? No. Looks good here. I would like to ask the author if you have closing remarks.

Just thank you so much for the opportunity to present this. We're very excited about a chance to actually eliminate deductibles for silver plan members and make a big dent in copays that are between them and getting the health care that they need. So respectfully ask for your aye vote. Thank you.

Thank you. We do have a motion from Dr. Arambula and seconded by Assembly Woman Boerner Horvath. Do pass as amended to appropriations. Madam Secretary, please call a roll.

Wood? Waldron? Waldron, aye. Aguiar-Curry? Arambula? Arambula, aye. Boerner Horvath? Boerner Horvath, aye. Carillo? Flora? Flora, aye. Vince Fong? Vince Fong, not voting. Maienschein? McCarty? Joe Patterson? Joe Patterson, aye. Rodriguez?Rodriguez, aye. Santiago? Villapudua? Villapudua, aye. Weber?

The bill is on call right now. You need one more? Obviously, we don't have all our members here, but thank you very much. Dr. Arambula is ready with AB 494. Proceed when you are ready.

Thank you, Madam Vice Chair and Members. I'd like to begin by thanking the Committee staff for the recommended amendments which I accept. AB 494 will protect farm workers insured through their union and boost the RFK Medical Plan. Farm workers are the backbone of California's economy and an essential part of our communities. Despite their significant contributions to our state farm workers continue to face a range of barriers that impede their access to health care including affordability.

The RFK Medical Plan is a health plan for farm workers by farm workers. With growing UFW membership and rising health care cost now is the time to reaffirm our commitment to California's farm workers. This legislation ensures that the thousands of families who are enrolled in the plan stay covered. Testifying in support of AB 494 is Areli Arteaga, representing the United Farm Workers.

Good morning. My name is Areli Arteaga. I serve as the Political and Legislative Director for the United Farm Workers in support of AB 494. This bill will allow both farm workers and their employers to continue contributing financially to their own health and allow the State of California to continue reducing Medi-Cal costs. AB 494 removes the sunset on the successful provision in the health and safety code and adjusts the current state's reimbursement cap.

The Robert F. Kennedy Medical Plan is a joint labor management health plan for farm workers organized under the 1947 Taft Hartley act. Through the RFK Medical Plan, the United Farm Workers and contributing employers deliver basic medical costs-- medical care, excuse me, at an affordable cost for over 6000 Californians and it includes approximately 2000 children. With the recent changes in California law there's a reasonable expectation that the number of farm workers covered under the RFK medical plan will increase.

That growth will explode upon to a high increased costs as well as the increase of the state's Medi-Cal savings which is currently at 11 million annually. We ask for your consideration. Thank you.

Thank you. Are there other witnesses in support? Name, organization, position only, please.

Good afternoon. Andrea Rivera, on behalf of the California Panethnic Health Network, in support.

Thank you. Any witnesses in opposition? Seeing none. We'll bring it back to the Committee. Any comments, questions from Committee? No. Would the author like to close?

Thank you for the opportunity to present and I respectfully ask for an aye vote.

Okay. We do have a motion from Assemblywoman Boerner Horvath. A second by Assemblyman Villapudua. Due pass as amended to Appropriations. Madam Secretary, please call a roll.

[Roll call]

Your Bill needs three votes. And once again, we don't have all our Members, so we will keep the roll open. It'll be on call. Thank you. Okay, in the meantime, we're waiting for our two authors. We can go back to some bills that we heard when we didn't have a quorum and go through the votes. It's items number two, AB 33. Item number three, AB 90. And item number 10, AB 1477. We can go through those and call a roll.

Okay, AB 33, motion and a second. Do pass to public safety. Madam Secretary, please call the roll.

Wood? Waldron? Waldron, aye. Aguiar-Curry? Arambula? Arambula, aye. Boerner Horvath? Boerner Horvath, aye. Carrillo? Flora? Flora, aye. Vince Fong? Vince Fong, aye. Maienschein? McCarty? Joe Patterson? Joe Patterson, aye. Rodriguez? Rodriguez, aye. Santiago? Villapudua? Villapudua, aye. Weber?

Okay, eight to zero that Bill is out. We'll move to item three, AB 90. Assembly Woman Petrie Norris. Do pass to appropriations. We have a motion and a second. Madam Secretary, please call a roll.

Wood? Waldron? Waldron, aye. Aguiar-Curry? Arambula? Arambula, aye. Boerner Horvath? Boerner Horvath, aye. Carrillo? Flora? Flora, aye. Vince Fong? Vince Fong, not voting. Maienschein? McCarty? Joe Patterson? Joe Patterson, aye. Rodriguez? Rodriguez, aye. Santiago? Villapudua? Villapudua, aye. Weber?

Okay, that Bill needs one more. Hold that open.

Put it on call.

And put it on call. Item number 10, AB 1477. Assembled Woman Quirk-Silva. We need a motion. Who was that? I don't know. Was that you, Mr. Patterson? Mr. Fong. Okay. Second by Dr. Arambula. Madam Secretary, please call the role to pass as amended to appropriations.

Wood? Waldron? Waldron, aye. Aguiar-Curry? Arambula? Arambula, aye. Boerner Horvath? Boerner Horvath, aye. Carrillo? Flora? Flora, aye. Vince Fong? Vince Fong, aye. Maienschein? McCarty? Joe Patterson? Joe Patterson, aye. Rodriguez? Rodriguez, aye. Santiago? Villapudua? Villapudua, aye. Weber?

That Bill has eight votes. It's out.

McCarty? McCarty, aye.

Nine votes. Okay, so now we wait for our authors.

We can go back.

Okay, so we are going to open up from the top to do add ons on Bills for those Members that were absent. Item number one. AB 29, calling the absent Members, Madam Secretary.

Aguiar-Curry? Carrillo? Maienschein? McCarty? McCarty, aye. Santiago? Villapudua? Villapudua, aye.

Ten to zero on that Bill right now. Item number two, we will take it off call AB 33. Call the absent Members.

Aguiar-Curry? Wood? Aguiar-Curry? Carrillo? Maienschein? McCarty?McCarty, aye. Santiago? Weber?

9-0 on that Bill.

Item number? item number three. To take off call, AB 90. Madam Secretary.

Wood? Aguiar- Curry? Carrillo? Maienschein? McCarty? McCarty, aye. Santiago? Weber?

That Bill now has eight votes. It has passed. Item number four. AB 228. Madam Secretary, call the absent Members.

Arambula? Arambula, aye. Carrillo? Vince Fong? Vince Fong, aye. Maienschein? McCarty? McCarty, aye. Santiago? Villapudua? Villapudua, aye.

12-0. Then we have consent calendar. AB 483, item number five. AB 365, item number 12. And item number 15, AB1462

15: AB 1462. Call the absent Members.

[Roll Call].

13/zero on the consent calendar, and Mr. Maienschein, you are here and ready to present Item 14: AB 1085.

Thank you. My colleague from San Diego. Thank you very much, Madam Chair and Members. 30 percent of all Americans experiencing homelessness are Californians with over 239,000 households living unhoused over the course of a year in our state. 45 percent of Californians experiencing homelessness live with disabilities. Homelessness dramatically impacts health outcomes, costs, and access to care. AB 1085 would require the Department of Health Care Services to seek any necessary federal approvals for Medi-Cal benefit to cover housing support services.

Housing support services help people access housing, remain stably housed, and are essential for individuals experiencing homeless to access meaningful care. These services include housing transition and navigation services, one-time housing deposits, and housing tenancy and sustaining services. With me, I have Sharon Rapport, on behalf of Corporation for Supportive Housing, and Linda Nguy from Western Center on Law and Poverty.

Good afternoon, Chair and Members. I'm Sharon Rapport, with the Corporation for Supportive Housing. We're a national nonprofit working to solve homelessness. We are one of the sponsors of AB 1085. Evidence shows housing support services are both critical to improving access to meaningful care and to decreasing health costs among people experiencing homelessness. Including housing support services as CalAIM Community Supports has allowed hundreds of homeless service providers to become network providers under CalAIM. However, it also makes provision of homeless services much more challenging.

Each plan designs their own eligibility criteria, authorization period, payment rate, referral process, and end date for service provision, and every provider must navigate this maze. Some providers report their administrative costs exceed the payment that they're receiving to provide the services. More importantly, as the analysis points out, because community supports must overall be cost-effective substitutes for other treatment, plans must undergo a cost benefit calculation. Studies show eligibility for health care based on costs leads to inequitable outcomes, often with people of color disproportionately underserved.

Acknowledging these limitations, the Department of Health Care Services staff have indicated that they would like to see a housing support services transition to a benefit. A housing support services benefit created under AB 1085 would allow California to tap into federal funding to pay for these services.

It would allow the state to standardize eligibility, authorization periods, and a process for referral and create an assessment that offers services based on need rather than costs. It'd be far easier for plans to administer and for providers to access. Moreover, AB 1085 would allow tens of thousands of people to stop living in pain and to start thriving and healing. I urge your aye vote. Thank you.

Good afternoon. Linda Nguy with Western Center on Law and Poverty, proud co-sponsor of AB 1085, here to read Theodore Patterson's statement, who had planned to join in person but was unfortunately unable to join. 'My name is Theodore Patton, and I work as a Speak Up Advocate here in support of AB 1085. In 2004, I was involved in a very serious accident and as a result sustained lifelong injuries.'

'I suffered a cracked lower disc in my back, which over time turned into a herniated disc and caused me severe pain. During this time, I also experienced mental health issues. After my accident, I became homeless and slept in my car. Because of the sharp pain from my injuries, I could not sit or stand for a long length of time.'

'I went back and forth from sleeping in my car to standing in line for over three hours every night at the Midnight Mission in Downtown LA, all in the hopes of getting a bed. With all my aches and pains due to my car accident, I often question how did I get here? Fortunately, a lady named Nancy called my mother's home and told my mother that she had a bed for me in the shelter.'

'I had been talking with Nancy for some time to get housing, but lost touch. To my good fortune, she reached out to my mother and eventually helped me get into housing. Without housing, I wasn't able to focus on my health as much as I wanted. For instance, I wasn't eating healthy or making my doctor appointments. Once I was housed, my priorities changed. I was able to eat more healthy, drink more water, and keep up my hygiene.'

'Most importantly, I had a bed to sleep in every night, which is very important for my back injury. Had AB 1085 been in place, I wouldn't have had to jump through all the hoops I did to get housing, waiting years, and made more difficult by my disability.' I appreciate the opportunity to read Mr. Patton's testimony and urge your support. Thank you.

Thank you. Assemblyman Maienschein, are you accepting the Committee amendments? Okay, thank you. Like to ask for other witnesses in support, name, organization, and position only.

Tara Gamboa-Eastman with Steinberg Institute, in support.

Vanessa Cajina, on behalf of CalPACE, in support.

Yasmin Peled, on behalf of Justice in Aging, in support.

Hi. Mari Castaldi, on behalf of Housing California, in support.

Thank you. Are there any witnesses in opposition? Seeing none, bring it back to the Committee for questions, comments at all? Seeing none. I did want to make a comment.

Sorry about that. I haven't yet buttoned up on my expertise on Medi-Cal; in the last 105 days, I've been a member. So exactly--I used to work here as a staff person, and we were making cuts to various Medi-Cal programs, or the Legislature was. I was not involved in that. As a result of the fiscal crisis ten years ago, plus, and reimbursement rates and things like that are still low, and so I'm just wondering how this impacts existing Medi-Cal programs, if at all, financially, and what it would do to those.

I don't think it would affect an existing program. This would be an additional service if it's approved at the federal level.

Reimbursed or--

Linda with Western Center on Law and Poverty. I'll just mention it has up to a 90 percent federal match rate, and so a significant federal reimbursement.

I'm going to guess not, but has the Administration commented on this at all at this point?

In our preliminary conversations with the Department of Health Care Services, they shared that their intent is to make housing support services a Medi-Cal benefit. In fact, they shot for a timeframe of 2024, and so that's part of the reason why we are sponsoring this legislation, as well as through their CalAIM initiative, making it a community support plan option.

Thank you.

Assemblyman McCarty.

Yes, thank you. I support this measure, and to that question, it is smart because 90 percent of the money we would get is from the federal government, so it's a good nine to one match there, but I think we all read today that the Governor and his state of the state tour talked about increased housing services, and there was an idea to use Medi-Cal for homeless for their first six months. So this is not that idea, but it's parallel and is the same concept, right? And in that idea, I think I saw that two states, Oregon and some other state, had already approved this idea.

I can respond to that. Sharon Rapport with Corporation for Supportive Housing. So what the Governor is proposing is taking advantage of something that the federal government has approved in Arizona and Oregon, and it's up to six months of rental assistance. So it's actually for the operating costs of a shelter or to pay for somebody to live in housing for up to six months. So this is actually what AB 1085 proposes, is to fund services that would be ongoing beyond probably six months, but what the Governor is proposing is actually paying for up to six months of housing.

I guess my question was--this is great; I'm in support of both those ideas--but in that idea, you said that there's two states that have applied to the Biden Administration and they got the waiver approved?

That's correct.

So has this concept been tried by other states been approved as well?

There are 19 other states that have benefits that fund these, and Arizona is one, as well as North Dakota, Minnesota. So some pretty bipartisan group of states.

Well, 19. My only beef is with Maienschein. What's taking you so long?

We're getting on it. We're just right behind North Dakota.

Okay. Great. Thank you. I support the bill and move the bill.

Assembly Member Boerner Horvath.

Yes, I already moved the bill, but I'm glad you're in the party, and I'd like to be added as co-author. It's a wonderful bill. Very smart. Thank you.

Thank you.

Just really quick, I wanted to comment that--and maybe the witnesses can chime in and add on if I'm erroneous in what I say--that currently Medi-Cal plans can choose to provide housing support services, and I remember we have discussed this in previous years as well, but there's different eligibility requirements. Counties are different. The standards are different. I know Mr. Maienschein has worked for many, many years, even previous to here in chronic homelessness and those issues in San Diego.

But having this be a statewide benefit would make it more available to people in Medi-Cal, more streamlined--that's the ultimate goal--plus the benefit of a 90 percent match with the federal, if that's approved and appropriated.

Yes, you're exactly right. It would make it more standardized. Right now, as you said, it's voluntary for the health plan so they can fashion the services however they see fit, and they're driven by seeing return on their investment. So this would allow them to actually receive payment for the services that they could be more standardized across the state, and there'd be federal funding for the service.

Okay, great. Thank you. Dr. Wood is back. Okay. So we do have a motion by Assemblywoman Boerner Horvath; second by Dr. Arambula. The motion: do pass as amended to Appropriations. Madam Secretary.

[Roll Call].

Your bill has nine/zero. It is out. Okay. Chairman Wood will be doing Item 16: AB 869.

Thank you very much, Madam Vice Chair and Members. AB 869 would help a targeted subset of financially distressed hospitals meet their 2030 seismic safety compliance requirements. This bill requires HCAI to provide grants to financially distressed small, rural, and district hospitals to pay for 2030 seismic upgrades and delay the completion date to 2035.

If funds are not available, financially distressed rural hospitals that have an estimated seismic cost of more than $1 million, or 2% of the hospital's revenue, whichever is greater, will not be required to comply with the 2030 seismic requirements until funds are available. This bill also includes a limited number of district hospitals that are not located in rural areas but are financially distressed, as determined by HCAI. Additionally, these district hospitals would need to meet at least one additional criteria.

One, they are located more than 30 miles or 30 minutes from another hospital, or they treat an above the average number of Medi-Cal patients, or they have already sought voter approval for financial assistance and the effort was not successful. We are all aware that many hospitals in California are experiencing difficult financial situations, but the hospitals covered by this bill have always faced financial challenges to the location and the populations they serve.

The bill is a targeted approach to preserve a small number of hospitals that are most often a community's only access to emergency care and will certainly close if some relief is not provided. Here to testify in support is David Neal, the Chief Executive Officer of Mad River Community Hospital, and Darren Beatty, the Chief Operating Hospital Officer of Plumas District Hospital. I respectfully ask for your aye vote.

Thank you, Chairman Wood and Vice Chair Waldron and Members of the Committee. My name is David Neal. I am the Chief Nursing Officer and Chief Executive of Mad River Community Hospital in Arcata, California. Mad River is a small rural hospital located in Humboldt County that has served the community for 50 years. I urge support of AB 869, which provides targeted relief to small and rural hospitals from the looming 2030 seismic retrofitting guidelines.

It is a critical legislation that gives ongoing efforts to the pandemic on rural hospitals that has been very laborious and helps save hospitals from closure by freezing up capital reserves that are desperately needed to meet ongoing operational losses. According to a recent report from the Center of Rural Health Quality, 55 rural hospitals in California are at risk, 16 at risk of closure and six in immediate risk of closure.

With Madeira Hospital recently closing, it has sent shockwaves throughout the state, not to mention the crippling impact it has had on the local population. Based on recent reports, such facilities as Hazel Hawkins may be next. Our hospital provides reproductive portion of women's healthcare in Humboldt County, as tubal ligations are not available at other secular hospitals in our county.

We also provide gender affirming care for a large female to male population in our area who would have to travel miles to receive their surgery if our hospital was not available. The closure of rural hospitals throughout California is a systemic problem that requires targeted solutions. Even before the pandemic, we operated in very tight margins due to low patient volumes in rural areas, inadequate reimbursement rates for Medi-Cal that has not gone up in over 10 years, and continuing rise in cost.

The pandemic only exacerbated these problems, requiring us to deplete our capital reserves to cover all time high costs, especially related to providers and travel nurses and their companies. Attempting to finance millions of dollars into seismic retrofit our single story, wood framed facility was not achieved before the pandemic and is out of the question now. To rebuild our hospital will require over $100 million.

As a single story wood frame building, our hospital has proven to withstand large seismic events during our 50 years of operation, as high as a 7.3 during this period of time. This last December, a 6.4. This was the third strongest in California history by G-Force and we sustained $40 in damage, a vase that was broken in our gift shop. Thankfully, AB 6869 recognizes there's not a one size fits all seismic solution. This bill provides necessary funding to allow rural hospitals to assess their seismic risk and provide extensions to the impending seismic deadlines based on our financial hardships.

Please remember California's hospitals are already among the safest structures in their communities with billions already invested in seismic compliances. AB 869 is a reasonable and achievable step in the right directions. In closing, I have spent 39 years in healthcare industry as a nurse and an administrator. I've never seen a more dire circumstance for hospitals, especially rural hospitals, than I see now. Seismic compliance is a multimillion dollar unfunded mandate that may well be the final straw.

I have worked large hospitals in Los Angeles, the Central Valley, and San Francisco, and I can truly attest to the fact that a one size fits all approach is not at all appropriate to the seismic solution. Rural healthcare is very different than urban healthcare. I strongly urge your support of AB 869. Thank you.

Thank you, Assembly Member Wood and Committee Members. My name is Darren Beatty, and I'm the Chief Operating Officer at Plymouth District Hospital in Quincy. Plymouth District Hospital is a healthcare district in rural northeastern California. As a district hospital, we were formed by the will of the people in 1957 to extend access to care to an underserved portion of the state. In 1959, with funding provided by the federal Hill Burton Act, a new hospital was built.

Sixty-four years later, we are caring for our community in that same building. State and federal lawmakers in the post World War II era understood that in order to extend care to poor and rural areas, direct assistance would be needed. That same need exists today. Some may ask why we have not yet complied with the state seismic mandate. Trust me, if we could afford to build a new hospital, we would have done so years ago. Our facilities in rural California face an infrastructure crisis, not all related to seismic.

More than anybody, we want modern and reliable facilities to care for our friends and families. A potential funding source for a new hospital is a general obligation bond. The problem with this source of funds is that it requires a supermajority, and that the fact that it levies a tax on the poorest of Californians at a rate they cannot afford.

A conservative estimate in my district places an average annual tax burden on my community at a rate of almost $700 per household for the next 35 years. After the devastating loss of more than 500 homes in 2021's Dixie Fire, the remaining community simply cannot bear this cost alone. AB 869 provides us additional time to locate a funding source to build a new hospital that we need in our community. If nothing happens, we face imminent closure.

Access to care for the people who manage the primary watershed for the California State Water Project will be gone. The independent delivery of care focused on the needs of the community will be lost. I thank Assembly Member Wood for his courage and leadership in elevating this issue and for presenting a bill that moves us towards modern healthcare delivery in rural California. Thank you.

Thank you. Are there other witnesses in support? Name, organization, position only.

Nicette Short on behalf of Adventist Health, in support.

Connie Delgado on behalf of the District Hospital Leadership Forum, in support.

Sarah Bridge on behalf of the Association of California Healthcare Districts and Rural County Representatives of California, in support.

Michael Rattigan on behalf of the Board of Supervisors of Santa Clara County, in support.

Thank you, Madam Vice Chair. Don Shinsky on behalf of the Structural Engineers Association of California. We are almost out of support. We're engineers, so the details are not worth supporting, unless we understand all the details, I guess, but we're just about there. We would ask we do have consensus that the bill remain focused. Thank you.

Hi, Catherine Austin Scott on behalf of the California Hospital Association. Really thank Dr. Wood for this bill and the introduction of this bill. We are support, if amended, like our rural hospitals, which we support in this bill. We have other hospitals that face the same struggles as both witnesses have commented on and wish to continue to work on those hospitals going forward. So supportive of Dr. Wood's bill moving forward and look forward to working on future bills on the same topic. Thank you.

Good afternoon. Matt Lege, on behalf of SEIU California. Just wanted to thank Dr. Wood for the continued conversation. Look forward to continuing to work with him on the bill. We do not currently have a position.

Thank you. Are there any questions, comments, from Committee? Oh, opposition? Is there any opposition to this bill? I overlook that part. Seeing none. Mr. Rodriguez.

I want to thank the Member for bringing this bill forward. Obviously, it kind of puts me in a very awkward position as Chair of Emergency Management Committee. We're always looking at making sure California is better prepared to respond to that earthquake. Right. And I know that it's very difficult in these rural settings. Right. Because of the funding, the location, and how unique you are to those communities. I like the funding component there, Assembly Member Wood. It's great.

I wish we can get more funding so we wouldn't have to continue delaying these projects, because we talk about keeping these hospitals open all the time. I'm also concerned about making sure that people that are treating the patients, the patients in there are in safe, secure buildings as well. I always look at California. I don't think we've been really tested on a major earthquake, whether it's up here or down south, to make sure that our hospitals in particular are able to withstand those earthquakes. Right.

Because worst case, some of these hospitals go down some of these buildings. I know it's very unique depending on urban or rural setting, but we just got to make sure we don't continue to kick this can down the road where we'll never get to that compliance. Right. And God forbid, once again, we have that major earthquake and we have some of these structures go down and cause additional issues to the workers and the patients that we're treating.

So I'm a very awkward position. I'm looking at to support it. Hopefully we can narrow these timelines where another 5, 10 years that once again, we don't seem to be kicking this situation down the road. But once again, thank you for bringing this forward. Look forward to continue working with you, and hopefully we can find a way to get that funding sooner rather than later.

And whatever we can do to help you, Assembly Member Wood, on that through my Committee, hopefully we can come up with something as we move this bill. Thank you.

Thank you. Ms. Aguiar-Curry.

Thank you, Assembly Member Wood, for bringing this forward. You and I share the same commitment, and we try to identify ways to address the challenges for our rural hospitals. Goes on and on and on every single year. Supporting what many times are the only facilities that our constituents can access care is absolutely essential to have health care access in both of our districts. We've seen this go on.

I've been here for six years, and we have something like this come up every year. I really appreciate you bringing the bill back and let's see if we can get across the finish line. And I would like to be a co-author, be added as a co-author.

Thank you.

Thank you. Mr. Flora, did you have anything? You're good. Okay, Dr. Weber.

Thank you, Dr. Wood, for this bill, for not only recognizing that some of our hospitals in our remote or rural areas will need a little bit more time and a little bit more assistance, but also some of our healthcare districts, which may not necessarily be located in a rural area, but have a payer mix which will not allow them the ability to have the funds earlier.

And so opening this up to them as well is extremely important because they do also serve a very crucial need in the community. And I agree with Assembly Member Rodriguez. We want our hospitals to be as safe as possible for that big earthquake if it ever comes. Let's hope it doesn't. But at the same time, we don't want to put too many constraints on the hospitals that we have so that they end up closing or not being able to serve the community. So it's a delicate balance.

I know we'll continue to talk about it here in Health Committee, but I just want to thank Dr. Wood and also ask to be a co-author, if you would allow me to be. Thank you.

Any other comments? Mr. Fong.

I'll just be brief. Thank you, Madam Chair. I just want to thank you for this bill. You and I have had number of conversations about financially distressed hospitals and providing them some relief, especially a number of them on the brink of closure. Madeira is certainly the canary in coal mine. Someone who represents the Central Valley, we have a number of hospital districts that are in the same boat. So thank you for this bill, and we'll also like to be added as co-author.

Any other comments from Committee Members? I too represent a very rural district. About 80% of the land mass of my district is rural, so it does affect our hospitals there. I'd like to ask the author if you'd like to close.

Yes. Thank you. And I appreciate that. This bill means a lot to me. You often hear me talk about the challenges of rural communities. This is a huge challenge for rural communities. A couple of years ago, we hijacked some money from the Vaping Tax Fund to help with this. Some of you may remember that. And I got people that weren't happy about it. I would have taken the whole freaking thing if I could have, quite frankly. But we didn't.

And we got some money, and there's money there that will help with some of the analysis for hospitals going forward here. But these hospitals are lifelines. And without a hospital in a community, they're often the major employers in some of our smaller communities. You lose your employers, you lose your hospital, and people leave. They'll move away because you have to have access to healthcare. And I appreciate concerns of Mr. Rodriguez.

I understand the delicate position he is in, and I would just say that, look, we want all these hospitals to be able to come into compliance, but we can't force them out of business in the interim here. When I think of, and I talk all the time about Mad River Hospital because they've sustained a 7.3, a 6.4 most recently. They haven't lost a day of service from an earthquake that I'm aware of in over 50 years.

And we have earthquakes every year, significant ones in our county, $40 in damage. I'm ready to write you a check for that. Many of these hospitals we're talking about are single story wooden structures that withstand movement well. And so we're just looking for a chance. We're threading a delicate line here. I know that we can't take every hospital in here because the nature of some hospitals are different. But I believe these are different. I think it's justified to move this forward.

And I hope that those that are on the fence or have concerns, especially some of the witnesses we heard, can get there with us, because this is a huge lifeline for people. And I thank you for your consideration. I thank you for those who've chosen to join me on this trek. I ask you for hard things sometimes. I do. That's just who I am. And we keep pushing forward on affordability and a variety of things, but this is personal. So I ask for your support.

Thank you. We do have a motion from Mr. Flora. A second from Mr. Fong. Do pass to Appropriations. Madam Secretary, please call the roll.

[Roll Call]

Your bill has 14 votes and is out.

Okay, last but not least, Item 17: AB 952, Chairman Wood.

Thank you very much. AB 952 is a bill to make it easier for consumers and dentists to know who and where to turn to when they need help with an appeal or with processing dental coverage claims. Sometimes patients call the dental office, the dental plan, the Department of Managed Health Care, or the Department of Insurance, only to find out that the employer responsible for their dental benefits is a self-insured ERISA Plan.

Honestly, I didn't really know what an ERISA Plan was until I came to the Legislature. I just knew there were different kinds of plans out there. Because it's an ERISA Plan, consumers are subject to federal laws, not the process in California regulated for California dental coverage. We are currently engaged with the California Association of Dental Plans to try to address their operational concerns and find other methods of notifying their enrollees and contracted providers. With me, we have representative witness from the California Dental Association.

Afternoon, Chair and Members. Jessica Moran with the California Dental Association, here today as the sponsors of AB 952. California has made great strides in increasing access to oral health care with an estimated of 86 percent of Californians having some form of dental coverage. While most dental insurance products are regulated at the state level by DMHC or CDI, over 40 percent of Californians with employer-sponsored coverage have dental insurance that is self-insured, also known as ERISA Plans.

These plans are regulated at the federal level and thus exempt from state regulations and rules. It can be difficult for both providers and dentists to determine if a plan is regulated by state or federal law. Oftentimes, a dental office does not know what type of coverage a patient has until after the billing process is completed, when they receive a retroactive denial or billing exemption for care they've already provided.

The lack of transparency also leaves patients without knowing who to contact if they have an issue with their plan. AB 952 is a simple yet effective way to increase transparency between dental plans, patients, and the provider. Under AB 952, dental plans would be required to disclose whether an employee's plan is subject to state or federal law at the time of determining a patient's eligibility for end benefits.

Receiving notification of what type of plan a patient has is critical to a dental office knowing the rules of the road when communicating a plan coverage to a patient. Additionally, AB 952 would require dental plans to provide the same disclosures on documentation provided to enrollees, such as insurance cards and online portals. At least six other states have passed legislation or regulations requiring dental plans to disclose whether plans are self-insured.

As California continues to move the needle in ensuring access to care, AB 952 is necessary to close the longstanding lack of transparency between dental plans and a protective patient-provider relationship. I'd like to close by acknowledging the California Association of Dental Plans's opposed unless amended position. We have begun discussions with them and will be collaborating on amendments to make sure the provisions in this bill work as we intend it. I respectfully ask for your aye vote. Thank you.

Thank you. Are there witnesses in support? Name, organization only, please.

Mel Assagai for the California Association of Orthodontists, in support.

Nora Lynn, on behalf of Children Now, in support.

Any witnesses in opposition, please come forward.

Thank you, Members. Matt Back, representing the California Association of Dental Plans. Obviously, Chairman Wood and the sponsor mentioned that we are in conversations. We certainly do not oppose the transparency piece and the disclosure. It's more on the operational side. Again, we've engaged in positive conversations and we look forward to a good outcome. Thank you.

Thank you. Seeing no other opposition, bring it back to the Committee for questions, comments? Seeing none, Chairman Wood, would you like to close?

Just respectfully ask for your aye vote. Thank you.

Thank you. We do have a motion from Dr. Arambula, seconded by Assemblywoman Boerner Horvath. Do pass to Appropriations. Madam Secretary, please call the roll.

[Roll Call].

Your bill has 13 votes. Thank you.

Okay. I apologize. I had to step out earlier, so I don't know where we are in the process, but we're going to find out real soon. Let's go to the top of the order. Okay. So I'm going to go ahead and we'll open the roll on Item Number One: AB 29, and call the absent Members.

[Roll Call].

That's 13/0. We'll go to Item Number Two: AB 33 by Assembly Member Bains. Please open the roll, call the absent Members.

[Roll Call].

That's 14/0. Item Number Three: AB 90 by Ms. Petrie-Norris. Please open the roll and call the absent Members.

[Roll Call].

That's 13/0. Item Number Four: AB 228 by Ms. Wilson. Please open the roll, call the absent Members.

[Roll Call].

That's 14/0. Item Number Five, 12, and 15 on the consent calendar. Please open the roll on the consent calendar. Call the absent Members.

[Roll Call].

That's 14/0. Item Number Seven: AB 632 by Mr. Gipson. Please open the roll and call the absent Members.

We didn't do six.

Number six?

Oh, you said seven.

Yeah. That's what I called was Number Six. Did I call?

No, you haven't yet.

Item Number Six: AB 632 by Mr. Gipson. Please open the roll. Call the absent Members.

[Roll Call].

That's 14/0. Item Number Seven: AB 948 by Mr. Berman. Please open the roll. Call the absent Members.

[Roll Call].

13/0. Item Number Eight: AB 1202 by Mr. Lackey. Please open the roll and call the absent Members.

[Roll Call].

That's 14/0. Item Number Nine: AB 1208. Please lift the call and call the absent Members.

[Roll Call].

That's 13/0. Item Number Ten: AB 1477 by Ms. Quirk-Silva. Please open the roll and call the absent Members.

[Roll Call].

That's 14/0. Item Number 11: AB 317 by Dr. Weber. Please open the roll call the absent Members.

[Roll Call].

Thank you. Item Number 13. Please lift the call and call the absent Members.

[Roll Call].

11/0. My--that was my bad. I meant to say AB 494 by Dr. Arambula. Sorry. Item Number 14: AB 1085 by Mr. Maienschein. Please open the roll. Call the absent Members.

[Roll Call].

And then Item Number 16: Wood, AB 869. Please open the roll, call the absent Members. There's only that one, so we're at 14/0. The next bill is that as well, so okay. With that, I understand Ms. Carrillo will not be able to make it. So at this point, we will go ahead and close the--this concludes our meeting. We'll go ahead and adjourn. Thank you very much.