Assembly Standing Committee on Health

Good afternoon. Before we begin, I'd like to make a statement on providing testimony at today's hearing. We seek to protect the rights of all who participate in the legislative process so we can have an effective deliberation on the critical issues facing California. All witnesses will be testifying in person, and we allow two main witnesses for a maximum of three minutes each. Additional testimony will also be in person and limited to name, person, and organization.

If you represent one, all testimony comments are limited to the Bill at hand, and we do not allow any signs or props of any kind throughout the testimony. We do have bills proposed for consent for today's hearing. Any member of the Committee may remove a Bill from consent.

The items proposed for consent are item number eight, Assembly Bill 845 by Assemblymember Alvarez item number 13, AB 1282 by Assemblymember Lowenthal, item number 14, AB 1239 by Assemblymember Calderon, item number 16, AB 1612 by Assembly Member Pacheco. The following bills have been removed from today's calendar Assembly Bill 660 by Assemblymember Irwin, Assembly Bill 710 by Assemblymember Shivo Item number 19, Assembly Bill 55 by Assemblymember Rodriguez and Assembly Bill 1751 by Assemblymember Gibson um, we do not have a quorum.

We do not have any other members. So it is our custom to not start until we have a representative from both houses or both sides of the house. So, cards, casual conversations, social media, look posts, whatever you're going to do, just hang out. Thank you.

Thank you. Mr. Patterson has arrived, so we can now begin our hearing. We appreciate that. Thank you. Our first bill. I see Ms. Soria here. Ms. Soria has item number one, AB 412.

Good afternoon, Chair and members. First, I want to begin by thanking our Chairman and also the committee staff for working with us over the last several weeks with our office to refine the Bill that is before you today. Your patience and cooperation through the process is greatly recognized and appreciated. So very grateful for all of the help.

For those of you that don't know, on December 22, 2022 which was less than three weeks from the day I was sworn in to represent the constituents of Assembly District 27, I learned of Madera Community Hospital's intention to close. Since that day, I've had countless meetings, briefings, and discussions with local, state, and federal leaders to try and find a solution, both short-term and long-term, to ensure continued access to care in the Central Valley.

The recent closure of Madera Community Hospital is a devastating health care crisis for the people, not just of Madeira, but the surrounding neighboring rural communities. Since the hospital's closure, Madera County has declared a local emergency due to the unprecedented impacts brought on by a community without a hospital. Fresno County followed suit with its own declaration of emergency because Fresno area hospitals are feeling the impacts of the closure as Madera community Members seek health care across county lines.

The reality today is that we find ourselves in a situation where over 160,000 people in the heart of California are without access to emergency health care services, labor and delivery services, surgery and specialty care in their own home county. Over 80% of people who sought care at Madera Community Hospital were Medical and Medicare patients, including patients who visited the hospital's rural health clinics in Chowchilla and Mendota, who are also now closed. These patients are mostly farm workers, Low-income working people, and essential workers.

Some patients even rode their bicycles and walked on foot to the hospital to seek care. Where do they go now? For those without reliable transportation, this is a matter of life and death. And we all know minutes can make a difference. In a wealthy state such as California, where we champion healthcare equity and declare healthcare a human right, we must ask ourselves, how did we get to this point? And most importantly, what will happen to communities in the Central Valley if we have another pandemic?

Where will people go? This past weekend, myself and a few legislative colleagues, including the Chairman, had the opportunity to visit Madera Community Hospital. What we saw was tragic. We toured a hospital with 106 empty beds, 16 empty ER beds, and 10 empty ICU beds. We stood in an empty labor and delivery room. We walked by an idle, state-of-the-art CT scanner room, and we saw hospital equipment draped in plastic sheeting and unplugged, unused and collecting dust. Empty.

No employees, no nurses, no doctors, and, more importantly, no patients. The closure has exacerbated the healthcare crisis that we face in our central valley. Out of the crisis, we must seize the opportunity for local, state, and federal leaders to stand alongside the community and find a way for the people of Madera to regain access to life-saving and preventative health care.

The closure of Madera Community Hospital represents an opportunity for us to think outside the box and demand that we not do business as usual from here in Sacramento. There must be a recognition that there are significant distinctions between urban and rural California and that the solution will not be a one-size-fits-all approach.

AB 412, which is in front of you, is an effort to provide immediate financial assistance to hospitals like Madera Community Hospital that have already closed but are trying to reopen, and also to provide a lifeline to hospitals teetering on the edge of closing. While Madera Community Hospital is the first hospital to shut down post the COVID pandemic, unfortunately, it may not be the last, but we have the opportunity today to make a difference.

Other hospitals around the state have signaled their threat of closure, including another hospital in the Central Valley, Korea Health Medical Center in Visalia, El Central Regional Medical Center in Imperial County. These are some of the most disadvantaged and already impacted communities that lack adequate healthcare services and doctors. AB 412 is simply a short-term solution that will help Madera reopen and be a lifeline for hospitals that are teetering.

I look forward to working with all of you so that there are no more closures that happen on our watch today. I respectfully ask for your aye vote.

Thank you. Witnesses in support. You have two witnesses that can speak for three minutes apiece.

Good afternoon, Mr. Chair, and the Members of the Committee. Thank you very much for allowing me to speak today, and thank you, Assemblywoman Soria, for your leadership on this issue. My name is Mohammed Ashraf. I'm a board-certified cardiologist who has been practicing Madera County for 42 years, since I was recruited by Madeira Community Hospital when I was finishing my fellowship at Texas Art Institute. Madeira County is a rural, medically underserved county. Most of our 160,000 people belong to minority groups, and many are Low-income.

In December 2022, as the Assemblywoman mentioned, because it had run out of funding and because a buyer withdrew its offer at the 11th hour, Madera Community Hospital abruptly closed its doors, leaving the county without any adult hospital. The issues that plagued our hospital, including Covid, Low Medical, Medicare reimbursement, and poor management, are very obvious. I also think you understand the negative impacts and the lack of health care has on a community and on efforts to achieve a just and equitable society.

Health is very important to maintain a healthy society. Today, I wanted to share what I'm seeing on the ground. My patients are terrified and they are going to die because they do not have the resources, whether that to be a right time off or money, to seek medical treatment at the next closest hospital, which is over 35 minutes away in Fresno. I've lost multiple patients myself, and I believe they've been living today, had Madera Community Hospital been open and provided timely, life-saving emergency treatment.

A few weeks ago, a patient having chest pain did not understand what to do, and where the healthcare available, drove herself to my office for help. I called the ambulance. She survived the trip to Fresno Hospital, but died soon after at home. To add insult to injury, the Fresno hospital was so overwhelmed that it took days to get me what I needed to be able to sign a death certificate, thus delaying her burial. We need a robust, comprehensive solution to the healthcare crisis.

But in the meantime, we also need emergency programs like what's envisioned in AB 412. If such emergency funds had been available to our hospital in December, we could have kept its doors open and saved lives. I urge you to vote in favor of AB 412. I've been in this town for 42 years. This is my only practice, and I sit next to the hospital. I see my hospital empty parking lot every single day. So it's not easy for me or for my patients.

And thank you for the opportunity to speak today. I will turn it over to my colleague, Dr. Ali Rashidian, who will also speak for the remainder of my time.

Thank you. Three minutes, please.

Thank you so much for having us and much appreciate your time. The Committee Member. I am Dr. Rashidian. I'm a triple-boarded physician specializing in pulmonary, especially lung diseases and critical care. What I practice, essentially, time is the essence. I take care of the sickest of the sick. We had 10 ICU beds in Madera hospital. They're all closed now.

I also practice in Fresno, and I see, unfortunately, some of the patients brought to Fresno with ambulance that, quite frankly, they don't even make it to the ICU rooms in hospitals in Fresno just because in ER, they pass away. It is extremely sad to see a huge community underserved, without basic needs of healthcare. They can't even get chest x-ray, which is the simplest thing, after 03:00 p.m, in whole county, I started my career after I graduated fellowship at Madera.

And in Fresno, I developed that ICU program. And after a few years, seeing it go away without any replacement, quite frankly, is heartburning. And unfortunately, as I mentioned, these patients, they can't even be seen in Fresno as an outpatient because of lack of adequate insurance. The only lifeline for Madera County and some of the surrounding county is Madera Hospital. We used to see medical patients that they would travel from Stockton to see specialties in the clinics in Madera. Those patients are without healthcare.

They can't even get their medication refill currently. And they can't even end up in any other ER simply because the other ERs are all full. And Fresno, every ER is essentially full of patients, and majority of them are. The higher impact comes from the Madera county. I respectfully and humbly ask you guys to consider this Bill and vote for it. So not just we open Madera Hospital, we can prevent another disaster such as Madera Hospital closing queue Delta Hospital, which is over 400 beds.

I don't even know what's going to happen, quite frankly, if that hospital closes, Hollister Hospital. So we really need your help to get this Bill passed, and hopefully we get some funding to get health care, basic health care, to the community that we all live in. Thank you so much for your time and appreciate you giving us a chance to speak.

Thank you. Please line up over here for any additional witnesses in support. Please just state your name, organization and position. Only Members of the Committee, yes please go first at the table.

Sorry. Kathryn Austin Scott with California Hospital Association, completely appreciate the members work on this Bill and look forward to working with you all on this Bill and the continued systematic underfunding of Medi-Cal that really is the root of many of these problems. Thank you.

Thank you.

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

Good afternoon, Mr. Chair Members. Connie Delgado, on behalf of the District Hospital Leadership Forum, in support.

Good afternoon. Taylor Roshen, on behalf of the California Fresh Fruit Association, in support.

Hi, Preston Young from the California Chamber of Commerce here today, in support.

Thank you. Chair Member Sarah Bridge, on behalf of The Association of California Healthcare Districts, in support.

Good afternoon. Sarah Dukett with the Rural County Representatives of California, in support.

Izzy Swindler, on behalf of Fresno Board of Supervisors in support and Madera County Board of Supervisors, in support. Thank you.

Nicette Short on behalf of Beverly Hospital and Peach, California's community safety net hospitals in support.

Thank you. Any witnesses in opposition? Do we have official opposition. So please come up to the table. You have three minutes for two witnesses.

Mr. Chairman, Members. Dennis Loper for the United Hospital Association. We are supportive, amended. We believe that all hospitals should be included in this Bill and not limited to keeping out investor owned hospitals with appropriate guardrails, you can be assured that the money is going to the use to keep the hospital open and if they meet the same stress levels, they should be included. Thank you.

Thank you. So we have a middle ground witness. Please come up.

Good afternoon, Matt Lege. On behalf of SEIU California, I want to thank the author and the Committee for taking this issue up. Think it's a really important issue. Do just want to see, as the Bill moves forward, continued guardrails around transparency, accountability and oversight as the money moves forward, and look forward to working with author and Committee on those conversations.

Thank you. Questions from Committee members. Yes, Mr. Fong?

I certainly want to thank the author for this Bill. Supportive. I certainly appreciate you acknowledging Kaweah and Visalia and, of course, the challenges that we have. We do have to probably do more broader. But I do want to ask, in terms of, from where you're sitting, I know there's specific criteria to determine what a financially distressed hospital is. Would you elaborate in terms of the criteria of the eligibility of the loan?

Thank you for that question, Assemblymember. So we have been working with the Committee and also other stakeholders to ensure that the Department, which I guess will be HCAI, will be delineating the criteria to ensure that those that are struggling are the ones that benefit from the Bill.

Is there any specific criteria you wanted to see or the ones that we should be as a Committee? Should we?

Yeah. So, for example, Madera obviously is really the driving force behind this. It's a recently closed hospital, and so ensuring that Madeira, who is now closed, is eligible, along with, I think that what we've talked about is looking at hospitals like yourselves. I think they've mentioned they have, like, 60 days cash. So looking at making sure that hospital like Kaweah also, which is short on cash, has the ability to qualify for the support or for the assistance.

So just to clarify, the Bill would have HCAI develop the criteria for that.

Yes

I don't know if the Hospital Association wanted to chime in here in terms of what the criteria.

I think the author had it mean. We've been working with the Committee and the author's office, and I think the amendments reflect that, we do want to make sure that there's a clear message to the community of hospitals that this Bill is going to help a very small set so that we can prioritize those that are sitting on the cliff, as we say. And HCAI will help work on that as we move forward.

But there is some consideration for making sure it's clear it's a small set because as we're worried, they're on the edge because we've had years of underfunding and we want to make sure we maintain the conversation around addressing the larger underfunding issues which the author is also authoring. Sure.

I certainly look forward to working with you as we develop the criteria. Want to make sure that these critical hospitals maintain and remain open. Thank you.

Okay. Thank you. No further questions. We don't have a quorum yet, so we will take this issue up later. Thank you. Next author, Mr. Kalra.

Yeah.

Ms. Soria, Assemblymember, one technical thing, you didn't agree to do the Committee amendments, so do you agree to accept the Committee amendments? Okay. Yes. For the record, we got that. Thank you. Sorry about that. Next author, Mr. Kalra.

Thank you, Mr. Chair and members, AB 486 moves the regulatory appeal process for class A and A appeals out of court and into an independent administrative hearing overseen by administrative lodge judge. Currently, nursing homes and long term care facilities licensed by the Department of Public Health have the unusual and singular privilege to file a citation appeal for the most serious violations that involve harm or death of a resident under their care in their local Superior Court.

However, our Superior Court system is overburdened and not designed to handle regulatory appeals. Facilities can also draw this process out for several years to reduce or overturn citations and avoid accountability. Despite being rarely issued when facilities appeal class AA and A citations, the state must expend considerable resources to defend the citation and has the burden of proof to substantiate the violation. Fortunately, there's a wellestablished administrative law process that can absorb and adjudicate these appeals.

This out of court process is less expensive, more time efficient, and consistent with other licensing appeals that are also usually handled by administrative law judge or regulatory appeals board. By making this long overdue change, AB 486 allows our state regulators to more effectively hold negligent facilities accountable so quality care for future residents can be improved.

Under this bill, facilities retain their due process rights and benefit from already being familiar with the administrative law process because class b appeals are often sent there, nursing facilities that appeal the state was overreaching in its citation or did not substantiate the cause of harm or death should not see this as an inferior process.

Recent amendments clarified that facilities still dissatisfied with the administrative law process, may file a 1094.5 writ in a Superior Court to review the factual and evidentiary record from the hearing to determine if the process was fair. The opposition has proposed keeping the status quo and adding the option for facilities to appeal using an out of court arbitration process.

For one, this does not address the problem and two, the American Arbitration Association process is not the appropriate venue for the severity and complexity of class AA and A appeals because the Department does not review the arbitrator's decision and cannot remedy the arbitrator's legal errors. If any. Nursing homes receive substantial state funding to care for some of our most vulnerable residents and in exchange we should expect quality care.

Unfortunately, our current system makes it very difficult to hold negligent actors accountable, and AB 486 is a balance fixed in that system. Accountability is the state doing its job at substantiating violations so a compliance plan can be made to prevent further harm and improve the quality of care for future residents. With me to offer testimony and support is so white Siam with Disability Rights California and Charles Antonin, supervising deputy Attorney General in the health, education, and welfare section at the California Department of Justice.

Thank you. Witness, please. You have three minutes.

Good afternoon, Mr. Chair and members, Sawait Seyoum here on behalf of Disability Rights California, and we are the proud sponsors of Assembly Bill 486. As California's designated protection and advocacy agency, the care and treatment of skilled nursing facility residents is a top priority for us. Our staff regularly go inside these facilities to investigate abuse and neglect and monitor the well being of residents.

From our decades of experience, we have concluded that robust oversight and regulation is essential to protect these most vulnerable residents. The current system, which allows nursing facilities really to drag out the appeals process for serious violations leading to death or the probability of death, gravely compromises that oversight. DRC investigated and analyzed hundreds of class A and AA citations issued when a facility's violation causes death or substantial probability of death of a resident.

We did find many instances where a facility received a lower citation despite serious negligence receiving, to name just a few examples, a resident receiving 50 milligrams of morphine instead of five milligrams a resident who used portable oxygen burning to death after smoking unsupervised a resident bleeding to death from multiple untreated pressure sores. This happens far too often and erodes public trust in our regulatory system designed to hold bad actors accountable so care can be improved.

The California advocates for nursing home reform reviewed the outcomes of 98 AA and a citation appeals and found that over 90% of them were settled out of court and that nearly every settlement included a reduction in fine or a reduction in citation class, or both. Assembly Bill 486 would move the appeals process where it belongs.

An independent administrative body that oversees the regulator, AB 486 to close provides a solution that ensures everyone's due process rights, but brings things into alignment with how things are done for other facilities and providers. It keeps the appeals processed before the administrative law judge who have the expertise to handle these appeals. This bill is long overdue, and it'll improve regulatory oversight to keep residents safe. We urge your aye vote. Thank you.

Thank you. Next witness, please.

Good afternoon, chair and members. My name is Charles Antonen and I'm a supervising deputy Attorney General in the health, education, and welfare section at the California Department of Justice. I am here on behalf of Attorney General Rob Bonta, who is proud to support AB 486, and thanks Assemblymember Kalra for carrying this important piece of legislation.

The administrative process envisioned by AB 486 would allow for the faster resolution of patient care regulatory violations because the discovery obligations and timelines for holding proceedings is streamlined compared to the current process. During my career at the California Department of Justice, I have personally litigated approximately 50 cases involving patient care violations at skilled nursing facilities. I have tried five of these matters to verdict. The current process used to challenge citations is an outlier.

It is an outlier nationally because only three other states use a similar process, whereas the Federal Government and every other state that regulates skilled nursing facilities uses an administrative process similar to what is outlined in AB 486. It is also an outlier within California jurisprudence because disputes between a licensee and its regulator typically involve an administrative process similar to what is outlined in AB 486. AB 486 is a common sense reform that will bring the regulation of skilled nursing facilities in line with these standards.

The current process poses significant organizational and practical challenges. As many lawyers in this room can attest, civil litigation is a cumbersome endeavor on a good day. In my experience, the fastest a contested citation can be resolved via the current process takes at least two years. One example I would like to share is that we are still actively litigating a Class AA citation. The most serious violations that was issued in September of 2019 after a multi week trial that concluded in January of 2022.

We are still waiting to receive the transcripts to finish the closing briefing ordered by the court. This is not unusual. Unfortunately, the accelerated timeline of administrative proceedings will allow for an expedited factual findings with only the most contested citations proceeding to a rid of mandate review in Superior Court. The accelerated timeline and streamlined discovery will shift costs downwards. This shift in cost will not change the likelihood of settlement or facilitate frivolous litigation.

Instead, AB 486 will lead to the expedited resolution of the majority of contested citations while maintaining important due process protections through the 1094.5 writ process. For these reasons, the Attorney General is in support of AB 486 and respectfully asks for your aye vote today.

Thank you. Any other witnesses in support, please line up and state your name, organization, and position only.

Good afternoon. Yasmin Peled on behalf of Justice in Aging, and the California Foundation for Independent Living Centers in support. Thank you.

Thank you. Anybody in opposition, please come to the table.

Good afternoon, Mr. Chair and members. Shane Levine, on behalf of the California Association of Health Facilities, AB 486 simply furthers the systematic deconstruction and erosion of our facility's due process rights.

To defend themselves against the most egregious of allegations, AB 486 builds on last year's AB 323 from Mr. Kaira. AB 323 effectively lowered the burden of proof in A and AAA cases, citation cases, and heightened the fines for these citations.

AB 486 unfortunately goes another step and removes our appeal of these citations from Superior Court and puts them into an administrative law setting and fast tracks these cases in a way that doesn't allow our facilities to adequately look at and seek evidence or depose witnesses.

These cases we are talking about here are akin to medical malpractice cases, typically in their level of complexity.

Over the course of many decades, the use of depositions and written discovery has brought to light significant inconsistencies and contradictions within the various interviews and factual investigations conducted by CDPH surveyors in individual citation appeals and the outright rejection of exculpatory facts by surveyors.

In addition, the deposition of the physician experts utilized by CDPH have uncovered serious issues with the professional experience required to qualify as an expert under established evidentiary standards.

The use of depositions and standard written discovery is essential in these cases if there are factual discrepancies or other serious questions about the citations cited. This is a critical element for all parties to consider before proceeding to trial. In these circumstances, settlement is often the right conclusion for the parties in cases that would otherwise settle.

Ironically, despite what the sponsors say, AB 486 will only operate to cause every citation appeal to go to a full blown administrative hearing that would reflect an enormous waste of resources.

If we are truly, truly interested in a shortened time frame to move these cases, then let's look at reforming the timing in the Superior Court process like we did successfully a few years ago on SB 1095 by then Senator Monning, but not by removing these cases entirely from the Superior Court process.

The desire here should be to maintain the sanctity of the judicial process and fundamental fairness to both sides. Unfortunately, this bill continues the multiyear effort to undermine this desire. For these reasons, we must ask for a no vote. And with me today is Scott Kiepen, an attorney at Hooper, Lundy and Bookman. Thank you.

Thank you.

Good afternoon, Chair and members. Thank you, Mr. Levine. As Mr. Levine just indicated, my name is Scott Kiepen. I'm an attorney at Hooper, Lundy and Bookman in San Francisco. I have had the honor of representing skilled nursing providers for approximately 28 years.

In that context, I have represented and managed a number of class AA, class A, and class B citations through both the Superior Court as well as the administrative form that's proposed by AB 486.

To expand upon Mr. Levine's comments, I have material concerns that the proposed bill would materially reduce the due process rights of skilled nursing providers by removing the forum from the Superior Court, where the California Code of Civil Procedure governs discovery, over to the administrative law context.

In that regard, I would like to stress again that class AA citations and class A citations are the most serious.

We do concede that, but in that regard, there are very serious allegations, allegations against the staff, allegations against the facilities have material consequences. The allegations, again, are such in the context of AA citation, that it's a determination or an allegation that the staff's care was a substantial factor in the death of a resident.

Likewise, with a class A double citation, it's a determination or allegation that the staff's care was or created an imminent danger of death or serious harm, or a substantial probability of death or serious harm.

In that regard, these are very serious allegations, and with that comes tremendous complexity, where you have a number of different facts, a number of different witnesses that need to be evaluated for the parties, not just the providers, but all the parties, to have a full discovery of all the issues so that you can actually lend itself to a fair adjudication.

You do not have that opportunity in the administrative law form, where the discovery is far more limited.

In the Superior Court, it's governed by the California Code of Civil Procedure, where you have opportunities of depositions, where you can actually explore and evaluate all the facts, all the issues confront the witnesses who made the decisions to issue the citations and the underlying witnesses that they otherwise gathered their information from.

That process is lost in the administrative law form, where I would characterize it more as an exchange of information as opposed to an opportunity to fully explore it through depositions, written discovery, and the like.

It's that lack of process in the administrative law form that materially reduces the due process rights. And I do respectfully disagree with my colleague from the California Attorney General's office. I, too, have tried, in fact, tried far more cases than five.

The verdict in these circumstances, I would say that actually these types of cases with the full value of discovery lends itself to resolution in advance of trial. I think that's valuable because under the circumstances, it provides a full exchange of information. Thank you.

Thank you. Any other witnesses in opposition. Please state your name, organization and position.

Sure. Darby Kernan, representing Leading Age California. Opposed unless amended. Thank you.

Okay, thank you. Any others questions or comments from Committee Members? Seeing none, you may close.

Thank you, Mr. Chair. As was indicated by our witnesses, I believe this is a common sense change that puts us in line with the majority of states and with the Federal Government that still allows for a process that allows for these particular cases to be appropriately adjudicated. I would respectfully ask for an aye vote at the appropriate time.

Thank you. You don't have a quorum here, but we'll hold this issue open till we establish a quorum. Next bill, Mr. Kalra.

Sodium nitrite is a chemical compound with no household use in high purity amounts, but has grown in popularity recently as a suicide method. I've learned a lot about this recently. It's pretty horrifying.

Thank you, Mr. Chair. AB 1210 has no opposition and simply requires labeling on sodium nitrite above 10% purity, stating it can be fatal if ingested, and that its recommended treatment is intravenous methylene blue.

When ingested, this chemical prevents the blood from carrying oxygen and can cause an agonizing death in as little as 20 minutes. Compared to 2018, 2021 saw a 253% increase in self poisoning with nitrites and nitrates and a 166% increase in fatalities.

The ease of ordering sodium nitride has made it a popular option amongst teenagers and other young people, leading to multiple lawsuits against Amazon.

One case filed in California, which has since moved to federal court in Washington, accuses the company of facilitating the suicides of a 17 year old and 27 year old. Another California suit accuses the company of enabling the suicides of a 16 year old and a 17 year old.

Some platforms, like Etsy and Ebay, have since made commitments not to sell this product. While methylene blue is a highly effective treatment for sodium nitrite poisoning, it is relatively unknown.

By creating more awareness of methylene blue, AB 1210 gives consumers and medical professionals the information they need to quickly treat sodium nitrite poisonings and increase the likelihood of saving lives.

Warning labels on shipping packages can also alert parents and other household members to a potential suicide attempt and allow them to intervene so their family member or friend can seek appropriate mental health assistance.

I think we're all familiar with packages that come to our home that you really don't know what it is. And young people of all ages are ordering things to their home these days, and I think this labeling gives parents a chance to have the opportunity to know what their child is ordering, especially when it deals with a product of this nature that's being used really in a non commercial sense at this concentration, it appears just for suicide and suicide attempts.

And so that's why this bill is important to really help inform consumers and certainly parents and other loved ones of the dangers of this product. Thank you, and I respectfully ask for your aye vote.

Thank you. Do you have any witnesses?

No witnesses.

That's fine. You're the witness. Author sponsored. Anybody in opposition? Nobody in opposition. Questions or comments from Committee Members. Wish to close.

Respectfully ask for an aye vote.. Thank you.

We will take this up when we get a quorum. Thank you for your presentation. Next, Assemblymember Pellerin.

Thank you chair and members. For many Californians, the access to behavioral health services in our healthcare system largely relies on an array of insurance options.

In addition to navigating the complexity of insurance options, barriers such as referral requirements and benefit limits often delay and restrict access to timely and quality behavioral health services.

Many family planning providers, like Planned Parenthood, that are widely accessible to younger and low income Californians already screened for drug and alcohol use, sexually transmitted infections, and intimate partner violence when a patient comes to them for reproductive health care.

Family planning service providers are uniquely situated to provide early, affordable, and accessible mental health and substance use screenings to patients, especially those who are younger women and lower income patients, to take the needed steps to improve long term health outcomes.

AB 492 establishes two pilot programs within the Department of Health Care Services to integrate the need for behavioral health with family planning and Reproductive Clinics.

One program will support Medical providers that are enrolled in the family planning, access care and treatment or family PACT program that provide reproductive and behavioral health integration programs.

The other program under this bill will provide grants to incentivize Medical managed care plans to develop and implement reproductive and behavioral health integration programs for patients.

Innovative pathways can help to provide these widely needed services, and the pilot programs initiated by this bill will facilitate access to Californians of all incomes and ages.

With me to testify in support of AB 492 are Christian Garcia, representing Planned Parenthood Northern California, and Andrea San Miguel with Planned Parenthood Affiliates of California.

Thank you. Please begin witness. You have three minutes per witness.

Thank you. Good afternoon, Chair and members. Andrea San Miguel, policy director for Planned Parenthood Affiliates of California. I'm here on behalf of the seven affiliates throughout the state who provide high quality, affordable health care at over 100 health centers, which leads to more than 1.3 million health center visits per year.

As the sponsors of AB 492, we believe the bill will support reproductive health patients access to integrated mild to moderate behavioral health services where they already seek care regardless of their insurance coverage or age.

PPAC's policy interest in supporting behavioral health screenings, referrals, integrated mild to moderate interventions, et cetera, in a reproductive health setting does predate the Covid-19 pandemic. However, 2020 and 2021certainly exemplified the role that affiliates could have in supporting behavioral health access.

As you will hear from an affiliate today, patient need continues to be seen in communities.

The pilot efforts in this bill will demonstrate how community health centers that primarily provide sexual and reproductive health services can be relied upon as part of the broader statewide effort to improve behavioral health access.

Planned Parenthood health centers are well suited to implement screenings and interventions for existing patients, 91% of whom are covered by medical family packed or are uninsured. Affiliates are doing what they can to make use of the no wrong door policy and contracting with managed care plans when possible.

However, building programs up to scale is what enables a path to sustainable funding for these services, then allowing to increased access for Californians.

In the past, our state has seen the benefits of integrating dental and behavioral health resources into other primary care settings. And it is our belief that in the coming years, it will be similarly evident that integrating behavioral health care into mostly sexual and reproductive healthcare settings will prove to be very helpful for timely access for patients.

With that, I'm here to answer any questions you may have about the bill.

Thank you. Next witness, please.

Good afternoon Chair and members. My name is Christian Garcia, Vice President of government relations and communications at Planned Parenthood Northern California.

I'm here today in support of Assembly Bill 492, which will create opportunities for behavioral health integration within Reproductive Healthcare centers across the state. At PP Norcal, we serve 20 Northern California counties with 17 health centers and a telehealth department. Many of our patients reside in some of the most rural parts of the state.

84% of them are from low income and 56 are from communities of color, vast majority 46% being Latino. Recognizing the interplay of physical and mental health, PP Norcal hired licensed behavioral health specialists that screen a multitude of behavioral health needs during visits.

Services include counseling for patients dealing with trauma related to partner violence, depression and anxiety symptoms, concerns related to accessing sexual and reproductive health care, and parental care and postpartum depression. Services are provided both in person and via telehealth.

Last year, the World Health Organization reported that the Covid-19 pandemic triggered about a 25% increase in anxiety and depression worldwide. This increase disproportionately impacted women, young people, and individuals with preexisting chronic illnesses.

At PP NorCal, the demand for behavioral health services and counseling has greatly outweighed our capacity because of low reimbursement rates for our patients who are seeking these mental health services. We simply lack the resources necessary to meet this patient demand.

AB 92 is critical in helping us expand the affordability of our mental health services to more patients. Currently, we have contracts with two reimbursement managed medical providers in Contra Costa County and in Solano County. That's two counties out of 20 that we serve.

All other patients must use our limited slidescaling model for fee adjustments to pay out of pocket for these essential and supportive counseling services.

AB 492, I believe, will set the path of improving these critical health care services, and this is why I respectfully ask for your support.

Thank you. Any other witnesses in support, please state your name, organization and position only.

Good afternoon. Andrea Rivera, on behalf of the California Pan-Ethnic Health Network, in support.

Thank you.

Taylor Jackson with California health plus advocates representing California's community health centers in strong support.

Thank you.

Alexis Rodriguez of the California Medical Association in support.

Thank you.

Izzy Swindler on behalf of California State Association of Psychiatrists, in support. Thank you. Thank you.

Thank you. Any witnesses in opposition? Seeing none. Questions or comments from Committee Members? Oh, coming up. Yes, please.

Nicole Young in opposition. Thank you.

Okay. Seeing no other witnesses in opposition. Questions or comments from Committee Members? That's you. No members. Two? Yes, seeing none. Three? Seeing none. You may close.

I want to thank Planned Parenthood for their sponsorship of this bill and the work they've been doing. We are in a public health crisis on mental health, and this bill takes an important step forward to make sure people have access to services. I respectfully ask for your aye 1vote.

Okay, thank you. We will wait until there's a quorum before we take action on this next bill 1471.

Thank you.

So again, thank you, Chair and members, and thank you for the opportunity to present AB 1471. This bill seeks to extend the deadlines for the three public hospital seismic compliance projects that are underway on the Santa Clara Valley Medical center campus.

Santa Clara Valley Medical center is a general acute hospital with 649 beds in San Jose.

Santa Clara Valley Medical center, along with O'Connor Hospital, St. Louis Regional Hospital, and 15 community health centers, comprise Santa Clara Valley Healthcare, the second largest public hospital and clinic healthcare system in the State of California.

Santa Clara County's hospitals and clinics serve a diverse population of more than 2 million Santa Clara County residents, as well as others that live in the Bay Area region and beyond.

Specifically, this bill extends the deadline from July 1, 2023 to July 1, 2025 for the Santa Clara Valley Medical Building F project from December 31, 2024 to December 31, 2025 for the Santa Clara Valley Medical center building and project and from January 1, 2025 to July 1, 2026 for the Santa Clara Valley Medical Center Old Main Demolition and Rebuild project.

These deadline extensions are unrelated to the 2030 seismic standards.

During the pandemic, the seismic work at Santa Clara Valley Medical center was impacted by the surge in demand for additional bed space. The county had planned to vacate areas of the hospital that were slated for seismic upgrades.

However, in order to address the needs of patients during the COVID emergency, Santa Clara Valley Medical center was unable to vacate the areas requiring work. Additionally, Covid impacted the construction workers on site, and isolation and quarantine periods related to Covid exposures and cases delayed.

The work continued and new issues are causing further delays and the projects will not meet the deadlines established in statute. The county has also had issues in soliciting construction bids and has needed to rebid various project components.

There are the added complications of a shortage of qualified construction workers and supply chain delays for equipment and supplies as well. Lastly, the project buildings were originally constructed in the 1930s and 50s.

As construction occurs, all existing noncompliant conditions must be brought up to code per Department of Health Care Access and Information requirements. This work adds time and cost to the work underway.

I have two witnesses with me today, Dr. Jennifer Tong, the Associate Chief Medical Officer for Santa Clara Valley Medical Center, and David Koenig, a Deputy Director, capital programs with the Santa Clara County Fleet and Facilities Department.

Thank you. Please begin. Three minutes per witness.

Chairman Wood and Committee Members. My name is Dr. Jennifer Tong, associate Chief Medical Officer for Santa Clara Valley Medical Center, which I'll refer to here today as SCVMC.

Santa Clara Valley Medical Center is our flagship public hospital offering an array of critical services for all members of our community, including a Level 1 Trauma Center, a regional Burn Center, and a Nationally Recognized Rehabilitation Center for spinal cord and brain injury care.

The county's hospitals played a critical role in responding to the Covid-19 pandemic, but unfortunately, the pandemic adversely impacted the schedules of the three seismic projects currently underway.

During the multiple waves of Covid-19 spanning from 2020 through 2022, SCVMC mobilized surge capacity, including staffing additional ICU beds. At times, we utilized every inpatient bed available, including our entire surge capacity.

To care for our patients, we needed to use the construction project's hospital space in our women's and children's building, which offered an increased number of private rooms, as well as negative air pressure rooms that were needed for infection control purposes.

Patient care was paramount during this unprecedented time. We could not choose construction over patient care, in light of the pandemic. AB 1471 would provide a needed extension of time for the three SCVMC projects to comply with seismic requirements.

If the project deadlines are not extended, SCVMC will not be able to use 150 of our hospital inpatient beds. The loss of 150 acute hospital beds would be catastrophic for the care of our community, given that, on an average day, nearly all of our acute care beds are in use. Thank you for your consideration.

Thank you. Next.

Good afternoon, Mr. Chair Members.

Doug Koenig, please press a button there.

I'm sorry. Can you hear me now?

Yes.

Okay. Good afternoon, Mr. Chair and members. I'm Doug Koenig. I'm a Deputy Director for Capital Programs with the County of Santa Clara. Thank you for the opportunity to provide testimony in support of AB 1471.

As described by Assemblymember Pellerin, the Covid-19 pandemic adversely impacted the schedules of the projects in a number of ways. Unfortunately, since the pandemic, we've experienced additional delays beyond our control and some unexpected, yet necessary design changes, which also added work and time to the projects.

The county has endeavored to meet the hospital seismic deadlines established in the statute, but due to the variety of circumstances and their impacts on the projects, we will not achieve compliance in time to avoid significant financial penalties imposed by HCAI.

If fines are imposed, funds that would be used for construction or for operational expenses of the county's hospital system and safety net, they would be diverted to pay for penalties. Thank you for your consideration of our situation and your support for AB 1471.

Thank you. Any other witnesses in support, please line up. Your name, organization, and position only.

Kelly Brooks, on behalf of the Board of Supervisors for Santa Clara County, in support.

Thank you. Any witnesses in opposition?

Good afternoon. Matt Lege, on behalf of SCIU, not in opposition. Just want to ensure that the conversations which started late last week around the construction and how do we preserve access to care continue.

We represent the workers at these facilities and just want to make sure our patients can continue to receive care and appreciate the author bringing the bill forward. Thank you very much.

Thank you. Questions or comments from Committee Members? Seeing none. You wish to close.

I respectfully ask for your aye vote, thank you.

Okay. On this one, we do need to know if you're going to accept the Committee amendments.

Absolutely.

Okay, great. Thank you. And we will hold this till later. We do not have a quorum. Thank you. And we do not have authors. Do we have any?

Okay, thank you. Assemblymember Rivas, please come up and present your bill.

Good afternoon, Mr. Chair and members. I want to start by thanking Lisa for her work and thoughtful analysis on this bill. I would also like to accept the amendments proposed by the committee.

AB 847 will ensure that children face illnesses at home through palliative care. This bill would allow young adults who have medical and with pediatric onset conditions to be eligible for hospice care after age 21 so that their care won't go interrupted.

Children with serious long-term diseases such as cancer and heart disease, are a growing population as medical advances allow them to live longer lives. With PPC's attention to quality of life, this type of care can help this population live a little bit more comfortably.

In 2014, California signed SB 1004, which changed the structure and funding of PPC so that home based care for children is provided the same way as it's provided to adult patients.

This bill inadvertently put youth receiving palliative care services at risk of losing this care if they did not meet the narrower criteria set for adults. Without adequate access to pediatric hospice, many seriously ill children will be unable to maximize their time at home with their families.

Today, I have with me to provide testimony Dr. Deborah Lotstein, Chief Director of the Division of Comfort and Palliative Care at Children's Hospital Los Angeles, and Patricia Everett, mother to Ryan Everett, a patient receiving concurrent hospice care. Thank you.

Thank you. Witness. You have three minutes per witness. Two witnesses. Thank you.

Good afternoon. I'm Dr. Deborah Lotstein, a pediatric palliative care physician at Children's Hospital Los Angeles. I'm here today in my role as co-chair of the Steering Committee for the Children's Hospice and Palliative Care Coalition of California.

The transition to adult medical care can be challenging for vulnerable children with chronic medical conditions and medica. At 21, they lose the supportive services they've received from our children's hospitals and also the California Children's Services program.

Children with serious illness who get palliative, or hospice care are among the most vulnerable of all. They have difficult to manage symptoms, require coordinated care, and for those receiving hospice may be nearing the end of their lives.

Under current law, after age 21, eligibility for home based palliative care is limited and youth can no longer receive concurrent hospice care. Families rely on these services to keep their children comfortable at home, and without them, youth may end up in the ER or in the hospital.

My patient, Miles, highlights the gap in the current system. At 19, he had a painful and disfiguring skin condition. He often missed appointments and his medications, leading to extra hospital stays.

But after enrolling him with home based palliative care, he had home visits with a nurse and a social worker. And with that extra layer of support, he could follow our treatment plan. He did so well, he was even able to attend community college.

Yet once he turned 21, he lost eligibility for the program, and at the same time, he was struggling to find new adult providers. He ended up with frequent ER visits. He ended up with frequent ER visits and struggled to get the consistent medical care he needed and still needs to fulfill his career dreams of working in healthcare.

AB 847 would allow pediatric home-based palliative care eligibility to continue to age 26 and provide a safety net for vulnerable youth like miles during the transition to adult care.

Ms. Everett, the mother of one of our patients, will share her experience with the other program discussed in this bill, concurrent hospice care. I respectfully ask for your aye vote on AB 847. Thank you for your time and attention to this critical issue.

Thank you.

Good afternoon. My name is Patricia Everett, and I am the single mother of a 22 year old severely disabled young man named Ryan. At birth, Ryan did not get enough oxygen to his brain.

He has severe cerebral palsy. He does not walk or talk, is fed through a tube in his stomach, and suffers from seizures due to his brain injury. My goal is to make him as happy and healthy as possible, given his issues.

When he was 19, on Christmas Day, 2020, before COVID vaccines, I found myself in the bathtub comforting my son, where he was having clusters of severe seizures. My dilemma, do I take my son to the emergency room and potentially expose both of us to Covid, or do I let him possibly die in my arms in the tub?

I made the agonizing decision that passing away in his mother's arms in a warm bath would be an okay way to die. Thankfully, he did not.

Our next appointment with Dr. Lotstein. After telling her about that awful Christmas Day, she strongly suggested that we sign up for concurrent hospice care, and it was a blessing. I had 24 hours access to nursing advice, a doctor, medications.

Afterward, I never had to take my son to the ER, nor did I have to have him hospitalized for seizures. We took care of him in our home and did not have to give up access to his other specialists.

When Ryan turned 21, he was discharged from his pediatric concurrent hospice. I would have continued if I could have. So I'm here to encourage you to allow other young men and women and their families to continue to have medical support in the home, where they are the most comfortable and avoiding hospital where it is often difficult, frightening, stressful, and very expensive. I strongly urge you to vote to support bill 847. Thank you for your time.

Thank you. Any other witnesses in support?

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

Thank you.

Good afternoon. Erin Taylor. On behalf of the Children's Specialty Care Coalition of California in strong support.

Thank you. Any witnesses in opposition? One more in support.

I'm in support. Yes. My name is David Bolog. I'm a member of the International Brotherhood of Electrical Workers, Local 18 in support of this bill.

Okay, thank you. Other witnesses in support? Seeing none. Any comments or questions from Committee Members? Seeing none. You may close.

And I respectfully ask for an aye vote.

Thank you. And she did accept the Committee Amendments, so those will be taken into consideration. Once we get a quorum, we'll take this item up. Thank you. Okay, next Member. I think Ms. Bains was here first, is that right? Yeah. Okay. Ms. Bainss.

Okay. There we go. Thank you very much, Mr. McCarty, for helping us out. I appreciate that. Assemblymember Bains, here you have AB 1122. Whenever you're ready.

Thank you. Chair and members, I would like to start by accepting the Committee Amendments and thanking the committee staff for working extensively with my office. AB 1122 addresses a critical piece of the medical provider shortage by targeting the administrative burden of the medical enrollment process.

Specifically, AB 1122 will require the Department of Healthcare Services to develop a process for applicants to submit alternative types of primary authoritative source documentation.

Additionally, this bill will provide common sense flexibility by allowing an applicant to submit their application up to 30 days before having an established place of business. State law establishes the fee for service medical program administered by DHCs under which qualified low income individuals receive healthcare services.

According to the state's own data, the number of medical providers is drastically low relative to the need.

This shortage is a significant challenge that threatens the health and well being of Californians who rely on this program for their medical care. As a physician in Kern County, I have seen the impact of this shortage on our communities, specifically, our rural communities. With limited access to providers, patients face long wait times or are forced to travel long distances to receive care.

A 2017 study published by the California Healthcare Foundation found that one of the main reasons for lack of participation in the medical program is the administrative burden that the medical enrollment program has on the physician office.

While AB 1122 will not completely solve the provider shortage, we hope to address a critical piece of the puzzle. By working together to streamline the enrollment process we can ensure that more healthcare providers are able to participate in the program, expand access to healthcare services, and improve the health outcomes of all Californians.

AB 1122 is supported by the Western center on Law and Poverty and the National Health Law program. Joining me today in support is Jeannie Vance. Thank you.

Thank you for having me here today. My name is Jean Vance. Thank you to the Members of the Committee for having me here today. I'm an attorney licensed in California and Hawaii, and I've been practicing for 29 years.

I'm a partner with the California law firm of Weintraub Tobin. I practice exclusively in the area of health law and in particular have a specialty in Medicare and Medicaid provider enrollment.

I speak and write both within the state and nationally for organizations on this topic, such as the American Health Law Association, the American Bar Association, and the California Society of Healthcare Attorneys.

The reason I have a specialty in this area of medical provider enrollment is because there are many administrative pitfalls that are there, like traps for providers that are difficult to determine what they are except through trial and error.

When a provider seeks to become a medical provider, things like, if you have a business license and the city that you apply to does not put your suite number on the business license, you will not be enrolled in the medical program. You may only submit your application for enrollment on the first day you're open for business.

If you submit it early and your application takes three or six months to review, they'll tell you at the end of that process that you submitted it 10 days too early. And the application requires the disclosure of, quote unquote, managing employees, but does, in fact, expect you to disclose folks that are not, in fact, w2 employees of your organization.

And so these deficiencies can cause significant processing delays and denials of medical enrollment applications.

The reason that this is important is because medical beneficiaries have a very difficult time finding physicians that are willing to treat them, and there are long waits for access to services. These issues are well recognized and long standing. Some of these burdens can be eliminated.

This bill would eliminate one of those reasons by allowing a provider to submit their application prior to the time that they're open for business. It would allow them to submit it 30 days ahead of the time that they are open.

I did have a client that submitted their applications for enrollment 10 days before the day that they took over, and their applications were in the review process for eight months or so.

And at the end of that eight month process, they said, oh, no, you submitted it 10 days too early, and in the meantime, they were not a medical provider during that time. This bill would help that and could do much more. Thank you.

Thank you. Others in support of the bill, just your name and organization if you represent one.

Linda Way with Western center on Law and Poverty in support.

Thank you.

Brandon Marchy with the California Medical Association in support.

Thank you.

Greg Hayes, on behalf of Pediatric Associates in support.

Thank you. Anyone else? Is there opposition to the bill? See no one. Bring it back to the committee for questions, or was I too quick?

Okay, not a question, but I think this is a great bill and what you just said. We all deal with the fact that we don't have enough medical providers in our districts.

And so at the appropriate time, I'd love to be added as a co author as well.

Thank you. I'd say. Anyone else? There's just three of us here now, so I guess not. Thank you very much for bringing this bill.

I know, certainly as having been a dental provider and actually knowing people that are trying to do that now, I think the application is 40 pages long and, yeah. Think things could be a little easier, quite frankly. So I appreciate you bringing this forward.

When we do have a quorum, we'll ask for a motion and move. The bill does enjoy a do pass recommendation. Would you like to close.

You know, I just wanted to close with a personal story. I was providing healthcare at the fire base in Sonoma when we had those big fires a couple years back.

And my Executive Director of Bakersville Recovery Services, for which I'm the medical director, for which is a residential based treatment facility for people in recovery from addiction, reached out to me and said, Dr. Baines, if I don't get you to sign this, they're going to pull our credentials within 24 hours.

I was literally caught treating firefighters and being threatened to take away our credentials for a residential based treatment facility. So the administrative burden is really real. I personally experienced it, and I thankfully and respectfully request an aye vote.

Thank you very much and we'll hopefully get a quorum at some point later today. Thank you so much, Mr. Lowenthal. Right, so you have two bills, AB 1164, which we'll ask you to present, and then AB 1282 is on consent. So if I were you, I'd leave that there.

You don't mind if I add a few more, do you, Mr. Chair.

Well, yeah.

Thank you, Mr. Chair and Members. Pleased to present AB 1164, which requires hospitals to develop and implement a response plan to alleviate crowding based on a real time calculator that measures emergency department crowding every 4 hours. This plan allows for rapid response with practical solutions based on the ever changing conditions in any given ED. California's emergency departments, or EDs, have become the healthcare safety net and are the front lines of public health emergencies. ED crowding is no longer simply an uncomfortable, time consuming burden for its patients.

It is jeopardizing the safety of the very patients for whom timely access to care is a matter of life and death. Crowding is often inaccurately considered a problem of ED operations and inefficiency. In truth, crowding is both reflective of hospital throughput, called boarding, and of health system dysfunction. Emergency department boarding occurs when a patient remains in the ED for more than 2 hours after the decision to admit them has been made.

As the ED becomes saturated with patients no longer requiring emergency care, it creates a backlog and impacts the ED's ability to care for all patients, whether they arrive in the waiting room or by ambulance. Boarding has been identified as a leading cause of ED crowding and a contributor to other problems, including ambulance refusals, ambulance wall time, prolonged patient waiting times, and increased patient suffering. Regardless of insurance, regardless of geography, ED overcrowding threatens the health and safety of everyone who goes to the ED seeking care.

By requiring hospitals to develop and implement a response plan, AB 1164 will help alleviate crowding based on a real time calculator that measures crowding every 4 hours. This plan allows for rapid response with practical solutions based on the ever changing conditions in any given ED. As outlined in the bill, hospitals will develop individualized plans tailored to their own needs and capacities, thereby providing flexibility which will go far in ensuring that plans will be adhered to to the benefit of all ED patients.

AB 1164 has the added benefit of helping hospitals and the state to coordinate regional and statewide disaster response. By utilizing the same crowding measure, hospitals will be able to communicate using a common language about the conditions they are facing. This allows for disaster response based on a real time measure of ED capacity.

I'm extremely pleased to be joined by Tim Madden here on behalf of the California chapter of the American College of Emergency Physicians, as well as Dr. Valerie Norton, the current president of the California Chapter of the American College of Emergency Physicians, who are here to testify in support of this bill.

Thank you, Mr. Chair. Madam Vice Chair, Tim Madden, representing the California Chapter of the American College of Emergency Physicians, and I'll make myself available for questions and defer my testimony to Dr. Norton.

Thank you, Chairman Wood and Members. We need this bill about emergency Department crowding because we are at a crisis point in hospital capacity. It's important to understand that ED crowding is due to crowding in the entire hospital. I want to give you some examples. Recently, we had a patient who missed a couple of dialysis appointments and came in with a dangerously high potassium level, which was causing heart arrhythmias.

Because our hospital was totally full, we didn't have an inpatient bed to send her to where she could get dialysis, and it's not physically possible to do dialysis in our Emergency Department. We gave her medications to temporarily lower her potassium level, but she spent two more hours in the Emergency Department while we scrambled to free up the bed upstairs and almost died several times of heart arrhythmias before we could finally get her up and get her on dialysis. Super scary. Not uncommon.

All my colleagues have many stories like this of boarding, and I want to point out that this bill is not just about taking a score. And by the way, it's really easy to get the score. I can do it in under 15 seconds with an app on my phone. Any medical record, any electronic medical record could be easily configured to report the score automatically. It will not take extra hospital time and staff. But the point is, it's not just about the score.

It's about having a plan for specific interventions at each level of crowding. We urgently need more hospital capacity, but in the meantime, we need to use our existing capacity more efficiently. There are lots of things hospitals can do to alleviate boarding, including discharging inpatients earlier in the day, assigning case managers to work on long stay patients that are having difficulty getting placed after they've had their hospital stay, smoothing the schedule in the operating room, evening the caseload amongst different hospitals in the same system.

With this bill, hospitals can choose the strategies that work best for their unique circumstances. We all need to be on the same page with these efforts, because hospitals depend upon each other to get patients to the right place for their care. When tertiary care hospitals are at capacity, they can't take transfers from other hospitals. We recently had a patient with an ulcer on the cornea of his eye that needed a special procedure, and we didn't have the right specialist.

We found an ophthalmologist at a nearby hospital who was willing to treat him, but the hospital refused to take the patient and transfer because they were completely full. So we admitted him and kept asking day after day to no avail. And finally, after two weeks, this poor patient's cornea ruptured, and he went blind in that eye. So this bottleneck has lots of spillover effects. On any given Monday, one third of my ED beds are filled with boarding patients.

Practically speaking, that means instead of having a 50 bed ED, I only have a 35 bed ED. My colleague from Fresno who's here with me today shared with me that out of the 195 patients in her ED today, 97 are boarding, waiting to be admitted, the longest for 53 hours if you can imagine that. We can't continue to function like this. I urge your aye vote.

Thank you very much. Others in support?

Jorge Fernandez, emergency physician representing California ASAP, in support.

Thank you.

Carrie Anne Dritton, emergency physician here in midtown Sacramento, in support.

Thank you.

Kamara Graham, I'm an emergency physician here in Sacramento, and I support.

Thank you.

Thank you, Mr. Chair and Members. Doug Subers, on behalf of the California Professional Firefighters, in support.

Thank you.

Clay Whiting, emergency medicine physician in San Diego, here for support.

Thank you.

Puny Gupta, emergency physician in LA County in support.

Thank you.

Hubert Wong, emergency physician in Orange County, in support.

Thank you.

Ron Wiggle, emergency physician in San Diego, in support.

Thank you.

Mark Vietnanik, I'm an emergency physician in downtown Los Angeles, and I support. I also represent a large national company called US Acute Care Solution. We have about 300 ERs. This is a major national problem. It's been going on for decades. It's time to fix it because it's getting worse.

Thank you. Anyone else? Is there opposition to the bill?

Good afternoon Chair Wood and committee members Vanessa Gonzalez with the California Hospital Association. In respectful opposition to AB 1164. Hospital emergency departments play a critical role in California's healthcare delivery system and stand ready to care for patients 24/7. As the author and Dr. Norton stated, due to several challenges in the entire healthcare delivery system, such as lack in primary care and an increase in patients in a behavioral health crisis, emergency departments have seen a 42% increase in patients and we expect this number to continue to rise.

During the pandemic and continuing today, emergency departments have proven their ability to be prepared, flexible, and responsive during volume fluctuations. AB 1164 would require hospital emergency departments to calculate and record a crowding score at least every 4 hours to assess its volume and capacity. Additionally, hospitals would be required to develop and implement six individual full-capacity protocols and file these protocols with the Department of Healthcare Access and Information. Hospitals throughout California currently use various tools and systems to assess patient volume.

Hospitals need the flexibility to use the methods that work best for each facility rather than be restricted to the sole method and formula specified in AB 1164. In fact, despite substantial published research, there is still no consensus around the best metric to measure and define emergency department crowding. Different studies in different emergency departments showed mixed results for the usability of the ED crowding score.

Additionally, because the scoring system in 1164 only considers a few specific factors and does not reflect the unique characteristics of individual emergency departments, such as varying patient populations, staffing levels, and physical layouts, this score would not fully capture the complexity of each emergency department. In order to meet the increasing demand of hospital emergency departments, hospitals have implemented several solutions such as adding additional beds, converting office and administrative space for treatment areas, hiring additional nurses and staff, and hiring patient flow consultants to improve processes.

Hospitals on their own keep track of crowding levels in the emergency department and already have plans in place to address overcrowding. The prescriptive approach in AB 1164 will not lead to significant improvements and will instead divert staff time away from direct patient care.

Additionally, as stated in the committee analysis, the full capacity protocol that hospitals would be required to plan and implement in this bill is substantially similar to the APOT reduction protocol required in another bill that the bill will be considering later today, which we have been working closely with the author and will address many of the same concerns because hospitals must be able to utilize the methods that work best for their facilities, we respectfully request your no vote on AB 1164. Thank you.

Thank you. Two witnesses, so I see three of you there, so whoever thank you. Thank you.

Good afternoon, Chair and committee members, my name is Monica Davila. I'm the chief nursing officer at Stanford Healthcare Tri-Valley. While we understand the importance of addressing overcrowding in emergency rooms, we are concerned about the implementation of statewide standardized overcrowding score protocols. Such a protocol as AB 1164 does not take into account the unique challenges and circumstances that individual hospitals and emergency rooms face, and it may be difficult to ensure consistency and accuracy in implementing such protocol in different facilities.

Would you mind pulling the microphone just a little closer? Sure. Thank you.

Furthermore, the implementation of such a protocol would create administrative burden for hospitals, taking away the very much dedicated resources that we need at bedside to care for our patients. At Stanford Healthcare Tri Valley, we implement a number of different systems and protocols processes starting with our EMR. Our epic documentation tool allows us to track census acuities, literally real-time, day to day, shift to shift allows us to pull reports. In addition to our epic tool, we also have organizational structures. We have daily capacity huddles.

We have patient flow committees, which our colleagues, our physicians, our clinicians attend to address barriers to address processes that we need to create as an organization institution so that we can ensure we have capacity and the adequate resources. So I do respectfully request a no vote for AB 1164, as this will continue to add administrative burden and pull those very much dedicated resources that we need at patient care away from patient care. Thank you for your consideration.

Thank you. Are there others in opposition in the audience?

Mr. Chair and Members, Amy Blumberg with the California Children's Hospital Association, also in opposition.

Thank you. Anyone else? No one? Bring it back to the committee for questions or comments. Anything, Dr. Weber.

Good afternoon, everyone. Thank you so much for bringing this bill and starting this conversation. I guess my first question when I read this bill was, what exactly is the purpose or what is the outcome that it is that you're looking for? So I think we all know that there's a problem in the emergency rooms. We have overcrowding. People go there not for emergent care, but they go there for urgent and sometimes just regular primary care that they should be going to a clinic for.

We've had that as an issue for a very, very long time. So anyone who goes to the emergency room or works in an emergency room, we know that there are long ways that there are a lot of people there. Anyone that works there knows that there is an issue with people being in the ER for a very long time, because there are no beds upstairs, there are staffing shortages.

For those of us that are physicians, it's not fun to have to go down to the ED to round on your patient that you admitted 12 hours before. But these are things that we already know, and these are metrics that hospitals have already looked into. So what exactly is the purpose of this particular bill? Because it would just reveal information that we already know, but not actually get at the crux of what the problem is, which is staffing or delays in discharge and things like that.

To me, it does seem like it's taking extra time or putting extra administrative burden on people that work in the ED to produce information that we already have and we already know.

That's an excellent question, Dr. Weber. Thank you for asking it. First of all, the scoring can be automated. It doesn't take anyone's time. Your EMR can spit out a score for you every 4 hours, and then it's incumbent upon the entire hospital leadership structure to figure out what to do at each scoring level. Most hospitals do have some kind of full-capacity protocol right now, but they're not adequate.

Some of us are blessed to work in systems like our colleagues at Stanford, where they've really done a lot of work on this, and I bet it's pretty good at Stanford, it's actually pretty good in my own healthcare system at Scripps, usually patients wait no more than three or 4 hours to get upstairs. But at Community Regional Medical Center in Fresno, we have a different story.

And there are a lot of hospitals in the state where it's a very different story and where we're hearing really, really scary, scary individual tales of horrible outcomes and horrible suffering. So we need hospitals to all get on the same page. We need our tertiary care centers to do what it takes to be able to accept transfers for higher levels of care hospitals, they could be doing all this stuff right now, but they're not. So we need to get them to do it.

We need to do something to get everyone on the same page, and there is research that shows that this works. When LA County USC started this system back in 2008, they were at a dangerously overcrowded situation by the scoring system about 40% of the time.

After they put their full capacity protocol into place and had levels that they responded to at each stage of crowding, they went down to where they were only dangerously overcrowded 1% of the time, and they were only just overcrowded about two-thirds of the time, which is pretty good if you know LA County USC. So it made a dramatic difference for them, and it's been done in dozens of other hospitals around the country as well. So we do have good evidence that it can work.

Thank you. So your assertion is that hospitals can do this? They just, at this point don't want to, even though it's been a problem for a very long time.

I think it's not so much that they don't want to as that there are many competing factors vying for hospital administrators time and attention. They also want to get their patients through the OR smoothly. They want to get elective surgeries done. There are all kinds of things that are impacting the ability to unload the ED. And sometimes it's not even about spending more money.

It's about deploying your resources differently, like having a long stay patient program or having a campaign with your doctors to make sure they discharge their patients by 10:00 a.m. That kind of thing can make big differences, but a lot of hospitals aren't doing these very simple measures.

Thank you.

Mr. Villapudua

So I'm glad you brought that up Assemblymember Weber. As a former county supervisor, I sat on all of our hospital committees, and these issues and concerns always came up. And I've had long talks with our CEO, which usually only lasts about three years. At hospitals, they rotate, which makes me ask the question, because as you hear, we'll shut down clinics in our communities, which drives folks to go to ER. And you're hearing more that more hospitals are closing down.

And so that's a scare because other hospitals don't want to hear that because now they're going to drive those hours in ER even longer. Right. But the question I have, is it really the Administration or is it labor or it's hard to get folks to go in those professions. Do we have enough? Is it a ratio number? I don't know.

I like what the author is doing, but I'm just trying to figure out, are we adding too much to this, to a problem that we know, it's not, not so much of the administration's issue. It's really kind of the issue of having either more doctors or more nurses in Central Valley, it's hard to get doctors and nurses there. They don't, they don't want to work there. They'll go to the Bay Area, LA. So it's always a racial issue there.

And I'm trying to figure know, I've been thinking about this all yesterday and today. How do we fix this without forcing the administration and telling them that they're not doing their job when they are? So is it a labor issue?

Of course we need more doctors and nurses. There's no question. I totally agree with you. We have a huge crisis in hospital capacity in this entire country, and it's definitely felt very keenly in California because we have the highest nursing wages in the nation and the lowest Medicaid reimbursement in the nation. So hospitals are all running on razor-thin margins.

So there's no question that hospitals are in distress and that we need more staffing, but we still have to do something with the resources that we do have. And there's lots of evidence out there that you can make differences just by changing how your OR scheduling is done, for instance, and allowing some cases to be done on weekends or in the evenings. Just by smoothing the flow of patients out of the OR, you can make a big impact on ED boarding.

A lot of people don't know that, but there's very good evidence for that. And many of the other interventions that I discussed also have a big impact. So we have to be creative. And we're not asking hospitals to come up with nurses out of thin air. We're asking them to have a capacity protocol at each level that they think they can do. We're not prescribing what they have to do.

We're saying, for your unique circumstances where you are, what can you do at each level of crowding, that's a little bit more than what you're doing right now.

So, just a couple of questions. So is it a one fix all? Because every hospital is different.

And that's why the interventions are not specified. So every hospital can decide on their own interventions for each level. But at least we want to be able to compare apples to apples in terms of what the score is for different hospitals. And during a Covid surge, wouldn't it be helpful, for instance, to know that El Centro regional is at a 197 out of 200, whereas Scripps La Jolla is only at an 83, and therefore we can take 10 of their patients and transfer.

That's really helpful information if you're the disaster management team trying to allocate resources in an area.

Thank you.

May I respond? Thank you. That's actually a very complex question that I ask myself every day. How do we solve for a lot of our capacity and overcrowdedness in our organization? And yes, at Stanford, we do have, we're fortunate to have some of the resources that allows us to really move capacity and patients through our organization. But we also recognize that there are organizations across the state that are not as fortunate.

Therefore, I think to the collective, implementing something like this is really putting a huge burden on the administration and the organization to pull away those bedside nurses, those clinicians that we so much value and are protective of so that they're not pulled away to figure out this administrative burden. We do have processes and protocols currently to address capacity, overcrowdedness, acuities. EPIC as an EMR is an EMR that has visibility and crosses many organizations across the state, not just Stanford, Sutter, many organizations.

So there is translatable knowledge and information across other organizations. So I think there's not a cookie cutter answer to a lot of the complexities. It is staffing, it is our providers, it is space, it's capacity, it's burden currently that we're seeing with our workforce. So there is no one answer on how to solve. But I think it does take all of us to sit down at a table and have dialogues and discussion about how to move forward as a healthcare organization.

Anyone else? Okay, first of all, the bill does enjoy a due pass recommendation, but a couple of comments. I want to thank you, Assemblymember, appreciate your work on this bill. We've seen several bills this year that are working to address the issue of ED crowding, patient boarding, throughput and ambulance patient offload time. Assemblymember Rodriguez in particular has been working for several years to address the APOD issue.

Should this bill move forward today, I encourage you to work with Mr. Rodriguez so that the protocols established in this bill are not duplicative of what he's attempting to do in AB 40. So we'll be watching that going forward. So with that, would you like to close?

Simply want to thank the members for their very thoughtful comments. We're keenly focused on them all. We are willing to work with anybody and everybody to strengthen this and are certainly concerned about how our hospitals feel. I want to reiterate what Dr. Norton said. We need to be able to talk about these things apples to apples. That is what this bill seeks.

So when Assemblymember Villapudua wants to talk about what's happening in hospitals in his district versus other districts, you have a commonality to be able to compare these things against. That is the fundamental part of what this bill seeks. Once again, we certainly appreciate all of the input. We'll be willing to work with everyone and anyone to strengthen this legislation. On behalf of all Californians, I respectfully ask for your aye vote.

Great, thank you. Well, as you see, we're getting closer to a quorum, but we're still not there yet. So anyway, thank you very much. Appreciate it. Mr. Lowe. Mr. Lowe, you have AB 1124 whenever you're ready.

And thank you very much, Mr. Chair and colleagues, for allowing me to present Assembly Bill 1124, which is a simple study bill, and I respectfully ask for an aye vote when you have reached a quorum.

Do you have any witnesses in support?

Yes. A brief or any technical answers, as they will provide them to you. Thank you.

Okay.

Thank you. Thank you, Mr. Chair and Members, for allowing me to address you today. My name is Dr. Julia Corcoran. I'm a licensed clinical psychologist in California, and I'm also the Director of Clinical Strategy at Modern Health. I'm also just a human being with my own and my loved ones' mental, health needs that are on my mind as I think about our mental health care systems in California. So while I'm here on behalf of Modern Health, I'm also here just thinking about the bigger picture.

Modern Health is an innovative platform that is looking to kind of broaden what mental health care looks like. We focus on mental health and well-being benefits for employers. Our mission is to improve the lives of people and their communities by offering inclusive mental health solutions that drive excellent outcomes and that is engaging.

We're very proud to offer programs to employers that assist their employees, as well as the employees' families, in identifying and addressing a wide range of mental health and well-being goals, including related to their emotional, professional, and interpersonal well-being. Our platform improves access to mental health care by offering services and resources that encourage individuals to engage in ways that are most suitable for them. We do that through digital programs, coaching, short term therapy, and, as needed, referrals to more significant care.

Thank you very much, Mr. Chair.

Thank you. Just to confirm, are you accepting our amendment?

Yes. I understand they're as submitted as author amends, is that correct?

Yes. Thank you. Thank you very much. Others in support of the bill? Please, just your name and organization if you represent one. Any opposition to the bill? Bring back questions or comments from the Committee. Seeing none, the bill does enjoy a do pass recommendation. We thank you for bringing it forward, Mr. Low. When we have a quorum, we will move for a motion and hopefully move your bill out of Committee.

Thank you. Thank you very much.

We're going to go ahead and move to Assembly Bill 659 by Ms. Aguiar-Curry. And I know her witnesses are upstairs. They're going to be coming down, so we'll give them a minute to do that. We'll wait just a minute until your witnesses arrive. Thank you. So following this bill, will take up Mr. Rodriguez's bill, AB 40.

Thank you for your patience, Committee and Chairman. Good afternoon, Mr. Chairman and Members. Mr. Chairman, I want to thank you and your incredible Committee staff for the many hours we've spent working on this issue for the past five years. Colleagues, in the United States, 37,000 cases of cancer are caused by HPV every year and over 7,000 people die per year from cancers caused by HPV, according to the CDC.

So while I've been waiting to bring this proposal to you, over 203,000 Americans have developed cancer and more than 35 people have died. Cervical, anal, throat, penal, vaginal, and vulvar cancers are caused by this virus and there is no way to know who will develop the cancer or other health problems from HPV. While some testing examinations can reveal coming health threats, others remain undetected until they become a threat to a person's life.

Despite all of the different types of cancer that HPV can cause, currently the only two ways for testing for and monitoring HPV are through pap smears and anal cytology. They are not failsafe and they detect the disease after it is already started. There is currently no standard way of penal testing of HPV in men and no approved or used way of HPV testing that can be done for the throat.

These limitations leave too large a gap in testing for and monitoring HPV, which is why HPV vaccination is a great preventative measure that can be taken to try to avoid numerous types of HPV cause cancers, especially the types that are not tested for. More than 135,000,000 doses of the HP vaccine have been administered in the United States since the vaccine was introduced in 2006.

The American Academy of Pediatrics recommends that young people get the HPV vaccine between the ages of 9 and 12 years because the HP vaccine is more effective if given at an earlier age and hopefully before being exposed to and contracting the virus. Despite this, the overall HPV vaccination rate in young people is as low as 51% in California, well below the national goal of 80%.

It is significantly worse in small and rural communities like mine and in communities of color and lower income communities throughout the state. AB 659 will require notification of parents in the 6th grade that the vaccination requirement for 8th grade is coming, giving parents ample time to consult medical professionals.

The bill will also require HPV vaccination of students 26 years of age or younger for attendance at the California State University, University of California, and California community colleges when students are still at the age where they can safely receive the vaccine.

AB 659 will guarantee that the HP vaccine is completely covered, regardless of health insurance status, by expanding coverage requirements for the HPV vaccine and expanding comprehensive clinical family planning services under the Family Pact Waiver Program to include the HPV vaccine for FDA approved patients. By requiring vaccination, this bill will help notify and educate Californians at these vital ages when receiving the vaccine is most effective. It will foster a private conversation between doctors, their patients, and parents, exactly what the opponents have said they support.

Doing so will prevent the spread of HPV and give more Californians protection from cancers and other HPV induced diseases. And for those who cannot or refuse to get the vaccine, it will offer them protection by decreasing the population who can pass it on to them. We have amended the bill so that school districts and higher education institutions are not required to confirm vaccination status for entry, meaning that is not a mandate. Again, not a mandate for school attendance.

Members, we have listened to school officials, parents, and mental health professionals about the impact of the pandemic on our youth, so we have decided not to bar entry to school for these new vaccine requirements. I have been questioned on why I would move forward with a bill that doesn't include enforcement requirements. Aren't you sacrificing the element that will have the greatest effect? I've been asked. I am willing colleagues to take this incremental step because it will still save lives.

Lives like the cousin I lost to from this preventable disease. If we can save one more family from that pain, one young woman's ability to have a family like the beautiful one I have. One young man from the terror of finding out that he may die or lose the ability to speak from cancer of the throat, then all of the work we've done on this bill for the past five years has been worth it.

Over 203,000 Americans have developed cancer, and more than 35,000 people have died since I began working on this important issue. We can't wait. Here with me today to speak in support is Dr. Jeffrey Klausner, Clinical Professor of Medicine, Infectious Diseases Population and Public Health Science, from USC Keck School of Medicine, and Erin Parris, founder of the youth organization Teens for Vaccines.

Please, you have to push that button. There's a button up there. Push the button there. Thanks.

Thank you for the opportunity to speak to you today. My name is Dr. Jeffrey Klausner. I'm a Professor of Medicine, Infectious Diseases Population, and Public Health Sciences at the Keck School of Medicine, the University of Southern California. I am also a former CDC medical officer and former deputy health officer for the city and county of San Francisco. I have a medical degree from Cornell University and a master's degree in public health from Harvard University. I'm board certified in internal medicine and infectious diseases.

I'm currently licensed in California and in active medical practice. I am here today to tell you why you must vote yes on Assembly Bill 659 and why the vote must be unanimous. Today in California, only about 50% of adolescents have completed the HPV cancer vaccine series. That leaves about half of adolescents incompletely or fully unprotected against those cancer causing viruses. The State of California considers HPV a known carcinogen or cancer causing agent.

The low population vaccination coverage results in an excess number of preventable cancers and HPV related cancer deaths. It is estimated that every single day, two Californians die. Two Californians die every single day from HPV related cancer. The HPV cancer vaccine was approved by the FDA in 2006. In the 17 years since its approval, it has proven to be very safe and highly effective. Safety concerns have never been validated in well done scientific studies.

Systematic reviews and metanalyses have found no association between HPV cancer vaccination and autoimmune disease, Guillaume Barre syndrome, or other supposed injuries. The first studies leading to the approval of the vaccine showed in randomized controlled trials the highest level of scientific evidence that the vaccine presented persistent infection. Further studies have shown that HPV cancer vaccination clearly prevented cancer, an 88% reduction at the population level in Sweden. In countries like Australia, where HPV cancer vaccination is routine, cervical cancers may be eliminated by 2035.

The HPV cancer vaccine prevents multiple vaccines cancers, particularly oral cavity and throat cancers, which are rapidly rising in males. Critics have expressed concern that vaccine requirements are not applicable to infections not spread in the school setting. In fact, many of the current recommended and required vaccines are acquired outside of school or the community. Tetanus, polio, hepatitis B, another cause of cancer, are not typically spread in school, but school entry requirements have resulted in the near elimination of those diseases among people born in California.

Lastly, I have personal experience taking care of patients with HPV related cancers, some of whom have died. One patient was doing very well living with HIV only to succumb to HPV related cancer. Another suffered through stage four throat cancer, highly preventable with vaccination. I urge all of you to make the rational decision, help protect Californians from cancer, reduce health disparities, and have the courage to do the right thing. Vote yes on AB 659.

Thank you very much and my apologies. We allowing a little extra time for everyone on this issue. So if I didn't mean to cut you off, Doctor. So my apologies. Error up here, please, to your next witness.

All right, so good morning, honorable Members of the Assembly Health Committee. My name is Arin Parsa. I am a 10th grader from San Jose, and I'm the founder of Teens for Vaccines, a youth organization with ambassadors across many states in the US promoting the life saving power of vaccines so all teens can lead healthy lives without worrying about preventable diseases. I'm here today to voice my strong support for Assembly Bill 659 so students like me can live without the fear of HPV, a cancer causing virus.

HPV is a preventable cancer, but our rates here in California among teens, especially in rural and low income communities, are really low, less than 30%, which is nowhere near the 80% goal that we aspire for. I got my two doses of the HPV vaccine when I was in middle school because I was fortunate enough to have routine Wellcare Doctor visits to keep all of my immunizations up to date. But not all teens are as fortunate as I was.

Some families are unaware that the HPV vaccine is most effective when administered to young people nine to 12 years of age. Other families simply can't afford to get the vaccine. So with Assembly Bill 659 requiring all public and private health insurance programs to cover the cost of vaccinating for HPV, we have a real opportunity here to close long standing inequities that affect so many teens. I founded Teens for Vaccines when I was in 7th grade during the 2019 measles outbreaks.

To me, it was shocking and also gut-wrenching that children and teens in modern times still face threats from the same diseases plaguing us 50 and 100 years ago. Since then, I have been tirelessly advocating for every child's right to life saving vaccines and healthcare. With the Covid-19 pandemic having ravaged our communities for two years, routine vaccination rates have fallen to dangerous levels. We know that HPV is the most common sexually transmitted infection, infecting about 13 million people, including teens, each year.

There is undeniable evidence that, left untreated, the HPV infection leads to cancer. Knowing that there is a safe and effective life saving HPV vaccine available, one that has saved millions of lives since 2006, we must protect every teen here in California. It is time we take action, and it is time we make reproductive health equity and AB 659 a priority. We have tremendous leadership here in California, and we have shown that in the past that we can forge a path and set an example. It's time to pass AB 659, the Cancer Prevention Act, so we teens can live happy and healthy lives without worrying about HPV. Thank you so much.

Thank you very much. Others in support, please. As I said earlier today, just your name, organization, no posters, no exhibits, just name and organization, please.

Hi, Shannon Olivieri Hovis with NARAL Pro-Choice California in support. Thank you.

Thank you.

Mr. Chair, Members. Rand Martin here on behalf of the AIDS Healthcare Foundation, which is also a major provider of STD prevention and care services, in very strong support of this bill.

Thank you.

Sochi Lopeziella, on behalf of Access Reproductive Justice in strong support. Thank you.

Good afternoon. Molly Robson with Planned Parenthood Affiliates of California in strong support.

Thank you.

Alexis Rodriguez with the California Medical Association in support.

Thank you.

Taylor Jackson with California Health Plus Advocates, representing California's community health centers in strong support.

Thank you.

Ryan Spencer, on behalf of the American College of OBGYNs, District Nine in support.

Thank you. Anyone else? Seeing no one. Is there opposition to the bill? We have two main witnesses. Oh, sorry. We have three witnesses here. My. My apologies. Oh, I'm sorry. My apologies. I didn't read all of my notes when we started here earlier, so we are allowing a third witness in opposition here to speak. So there's a total of nine minutes altogether, please. Whenever you're ready.

My name is Joshua Coleman, and I am co-founder of V is for Vaccine, the world's largest vaccine risk public education organization. All vaccines are different. So when discussing a particular vaccine, it's important to do a cost versus benefit analysis. This bill, AB 659, would be promoting uptake of the HPV vaccine. There is only one HPV vaccine available, and that is Gardasil Nine. So I'm going to talk specifically about this vaccine. I have here the vaccine insert for Gardasil Nine.

The safety studies by Merck Pharmaceuticals, the company that makes the vaccine, showed that 2.3% of people who received this vaccine experienced serious adverse events. The FDA that has all the vaccine inserts available on their site, defines a serious adverse event as hospitalization, initial or prolonged, disability or permanent damage, life threatening condition, and death. So that's the cost. Now, what's the benefit? In the United States, for the past 20 years, cases of cervical cancer have not exceeded more than eight per 100,000 people.

So, doing the analysis, if 100,000 people are vaccinated with the HPV vaccine, at best, eight cases of cervical cancer might be prevented. But at the same time, 2,300 people, 2.3%, will experience serious adverse events. Do you think the benefit outweighs the cost? Also, keep in mind cervical cancer is not a death sentence. Out of that same 100,000, the rate of death by cervical cancer is two.

If you still want to proceed with this, our big concern is that the notification that will be sent to students and parents stating that it's public policy and it's expected will lead many to think it's legally required to get this vaccine in order to attend school, especially for our nonenglish speaking students.

If the authors of the bill are not seeking to deceive people into thinking this, we would ask for an amendment that the notification include the following statement, quote: "While the HPV vaccine is expected, it is not legally required. School entry and attendance will not be denied based upon HPV vaccination status," end quote. Additionally, Gardasil Nine is different from many vaccines where both the manufacturer and FDA advise against anyone pregnant or actively trying to get pregnant to take this vaccine.

So we also request an amendment that it is stated in the notification, quote: "It is advised by the FDA and Merck Pharmaceuticals that those who are pregnant or trying to get pregnant do not take the HPV vaccine," end quote. An individual making their own choices on what to do with their own bodies is extremely important and coercion by deception is outright unethical. Please make it crystal clear to Californians that this is not a required mandate for school attendance. Thank you.

Thank you. Next witness.

Good afternoon, Members of the Health Committee. My name is Karina Powers, founder of Latinos for Medical Freedom, a member organization with convention on health rights with the consortium of organizations advocating for health rights. Latinos for Medical Freedom represents thousands of individuals, many non-English speakers, and those with limited English proficiency throughout the State of California.

While AB 659, the Cancer Prevention Act, is well intended by providing expanded coverage for HPV vaccines and cervical cancer screening, it is unfortunately misleading, coercive, lacks clarity, and is confusing and authoritative to countless children and their families, notably for non-English speakers and those with limited English proficiency in California. Despite the amendments with the word state, public policy and expected as stated in the bill, language are problematic. An expectation is an order.

Many of our families, as well as students will interpret this as a mandate. AB 659 coerces our most underserved and vulnerable families to go against their personal medical decisions in order to comply with perceived requirements. Additionally, there is no requirement outlined in this bill to provide a written notification in languages other than in English, which denies these families proper informed consent. As trust in medical public health is declining in these communities, this will further diminish their trust in the public health.

As we have witnessed in the past several years, many of our children have faced much discrimination, social, emotional, and mental health struggles due to in person school closures as well examples of coercion in various school districts to comply with public policies in relation to the COVID vaccine. We have seen examples of coercion and incentivized in the way of food such as pizza parties and electronic devices in exchange for receiving the COVID vaccine. It is possible that the state policy could be utilized in the same way.

The expectation in the state policy language currently in the bill offers no guardrails for students on IEP nor families with non-English speakers and those with limited English proficiency. I ask you to consider these families and encourage you to oppose this bill unless amended to add language to clarify that the HPV vaccine is recommended but not required. Thank you.

Thank you.

My name is Catherine Swazil Roby. I'm a lifelong Californian and I live in Pasadena, California. I'm here representing my family. I oppose AB 659. My daughter Jennifer suffered a severe adverse reaction to the cervical cancer vaccine Gardasil as a teenager. The HPV vaccine caused debilitating and devastating injuries. My daughter was a high school athlete, an honor student, and had to drop out of school and has been disabled for over a decade. Jennifer has been bed-bound and wheelchair bound for extended periods of time.

The Gardasil vaccine has destroyed my daughter's life and devastated our family. The cervical cancer vaccine Gardasil has been grossly mismarketed by its pharmaceutical manufacturer, Merck. Merck has oversold the efficacy of the vaccine and concealed safety risks. The Gardasil vaccine, in addition to being dangerous, is also misleading. The best way to prevent cervical cancer is the pap smear. Cervical cancer mortality rates in the United States has been at a steady decline for decades due to the widespread use of PAP screenings.

Merck's own literature states that the cervical cancer vaccine does not remove the need for cervical cancer screening, does not treat HPV infection, does not protect against pre existing HPV infections, does not protect against HPV strains not covered by the vaccine, and may not fully protect each person who gets the vaccine. It is an expensive and optional add-on treatment. It is important that the public is aware that the best way to prevent cervical cancer is the pap smear.

AB 659, as it currently stands, uses language that is deceptive and intentionally misleading and would lead the average Californian to believe that the state is mandating cervical cancer vaccination for 8th grade through college students. The words expected and public policy of the state are coercive, and the bill needs to make clear that the vaccine is only a recommendation and not a mandate. It needs to be expressly stated that students will not be denied access to education if they choose not to get the cervical cancer vaccine.

I would hate for another family to have to live through the nightmare my family has had to endure or have their children denied their right to an education because they lack medical literacy. I believe it is inappropriate for the state to be recommending a vaccine with serious side effects for school age students because the HPV vaccine is designed to treat a sexually transmitted virus. Students are not at risk of developing HPV in the classroom setting. HPV, once transmitted, does not turn into cervical cancer overnight.

If the disease progresses, it takes years to develop and the age group being targeted by this bill is not at risk for cervical cancer. I would like to know that there are currently hundreds of lawsuits in the United States, including in California, against Merck for serious injuries caused by Gardasil. I strongly urge you to vote no on AB 659. The vaccine is dangerous, it is being intentionally mis-marketed, and it is guaranteed to injure innocent Californians. Thank you.

Okay, thank you. Others in opposition? Just your name, organization if you represent one, and position on the bill.

Nathan Pierce, Private Home Educators of California. Our position is currently opposed unless amended.

Thank you.

Olivia Mikos, co-founder of V is for Vaccine, oppose unless further amended.

Thank you.

David Ball, resident of Sacramento County, and I oppose.

Thank you.

Paul Roby from Pasadena, California. I strongly oppose.

Thank you.

Wendy Beal, on behalf of Moms for Liberty, Placer County and over 2,000 members, we strongly oppose this bill.

Thank you.

Nicole Young, Placer County, strong opposition.

Thank you.

Dahlia Epperson, founder of Act Monterey Bay. And we strongly oppose this bill.

Thank you.

Amanda Quintero of San Joaquin County, strongly opposed unless further amended.

Thank you.

Ms. Valdez from Monterey County, strongly oppose.

Thank you.

Kasia Williams, on behalf of California Parents Union, representing thousands of members across California, asking for a no or abstain on AB 659. Thank you.

Thank you.

David Victor Bolog, Los Angeles, in opposition unless amended.

Thank you.

Jeanette Phelps, Sacramento County, opposed.

Thank you.

Evelyn from Alameda County, and I oppose.

Thank you.

Roslyn from Alameda County and I oppose this bill.

Thank you.

Heather Jimenez from Hayward, and I oppose unless the language is amended to be not required.

Thank you.

Stephanie Gonzalez, Sacramento County, opposed.

Thank you.

Stephanie Degree, representing California Nurses United. And we oppose the bill unless further amended. Thank you.

Thank you.

Elizabeth Southwell, San Bernardino County Patriots, from Barstow, and oppose this bill.

Thank you.

Sarah Martinez from Concord, and I oppose this bill unless amended with language.

Thank you.

Corinne Whitlow, co-founder of Take A Stand Stanislaus. And we oppose unless amended.

Thank you.

Rachel Catan with Stand Up Sacramento County and Natomas USD for Freedom. Opposed unless amended.

Thank you. Anyone else? So, you know, bring it back to the Committee. Questions or comments from the Committee? Mr. Patterson.

Thank you, Assembly Member, for changing your bill and amending it a few times. I think based on, obviously, feedback, I think I didn't have the privilege of being a Legislator the last several years, but I know there was a lot of activity here, largely or not largely, but at least in part because of various vaccine mandates. And I think coming into this year with that sort of on people's minds was concerning to me when I saw this. And I think you've put a lot of time and thought into it.

One thing that I'm still debating, look, honestly, I don't know a lot about the vaccine. I'm not a doctor. I'm not a scientist. I guess now I'm a politician, right? So I can just read what people tell me and some concerns or issues that are raised. All my kids are vaccinated for everything. And I haven't really considered the HPV vaccine. I have two daughters and two sons, and it hasn't been something that I've thought about.

But when I was, I used to be a legislative staffer. I got my first internship over a decade, 20 years ago now, believe it or not, I know I'm young and handsome, but it was 20 years ago. And I remember sometime around 2010 or so, we started discussing at that time some legislation around the HPV vaccine. And I don't really remember what it was exactly at that point. I think it was a mandate, actually, but I don't actually know that.

And so for some reason that was pulled back and I don't really remember all the details. But one thing that does kind of concern me, I think making the recommendation to parents, and I think notifying parents, actually, I have legislation on the dangers of fentanyl that parents would be notified of that. And I look at as, hey, 6 million parents will receive notification of the dangers that are out there. And I think informing parents about the dangers of cancer could be a good goal.

And I mean, actually something that I would consider, because people die from fentanyl poisoning and people die from cancer, and we need to do everything we can to prevent that. But one thing I do get concerned about is a judge making the determination that this is the public policy of California to expect that children are vaccinated with this. And I don't think I'm quite there yet.

There are a lot of judges in California that may make some good decisions, some bad decisions, some that we could all agree or disagree on. But I do get concerned about one. And if you've put some thought into that particular statement about a judge making that ruling one day, I'd appreciate, obviously, your comments on that. But again, I just want to say I appreciate you working on this bill and paring it back a little bit. And I know it's really important to you. So thank you.

Thank you very much for your comments, Assembly Member Patterson. I appreciate the fact that you realize that we've worked really hard on this. I think I've spent a lot of time, and I know I've spent a lot of time with some of the people that are here in the audience that opposed the bill to make sure we got it right. We're not going to always make everybody happy, but I worked really hard on the question is, does the bill not mandate the HPV vaccine?

While the bill sets requirements for students at the high school and college university level, the institutions included in this bill are not required to confirm vaccination for entry or enrollment. Give some time for people as they have their children go to the doctor, have a conversation with the doctor. They can be notified that this HPV vaccination is due if they would like to take it. And the family can spend some time realizing, is this right for my child?

Do they have compromised immune system or whatever the case might be? I think the education piece is really important. Like I said, I wish I could get everybody to get this vaccination. I've seen too many people die from this and it's hard. It's really, really hard. It's something we could prevent, and why wouldn't we want to try to prevent something? So with that, I just think that I appreciate the opposition. I will continue to work with them.

They know that. I have had really good conversations with them. We may not come to a place that we all agree on, but I've been a listener and I have not said they couldn't see me. I have taken their information. It was important. We were concerned about kids getting back to school. I thought that was really important because of COVID. We don't need to add another barrier for kids not getting to school. Right? And I think I really paid the attention and that made a lot of sense to me. So with that, I'm hoping that answered your question, Assembly Member.

Would you mind if I just, I don't want to take your last, you'll get the last word, of course, as the author of the bill. But just something to consider moving down the line is maybe some intent language or clarification just to a future court that this shouldn't be interpreted to be a mandate. Obviously, we're having that discussion now. Right. But no judge is going to go back and watch this video. I won't even go back and watch the video.

So just something to consider down the line. I do get concerned, like I said, about a judge, but I do appreciate you listening to the opposition on this. And although I have concerns now, I really appreciate your sincerity in working on this issue. Thank you.

And I appreciate you bringing up the judge. I won't say anything else.

Mr. Villapudua, do you have a question? Comment?

Yeah, just more of a comment and a question. First, I do want to thank everyone that showed up today and the author. I mean, this is one of those bills that I can honestly say that it's aged me. Right. Because you're going back and forth working with folks. Everyone's calling you. I don't know how many long talks I had with the author over this. And she was a great listener in trying to figure out how do we get this?

I won't say across, but she was really working hard to accomplish where she's at now. The only comment that I have, too, is that I think of my mom, who would turn to us when she couldn't understand something, if it's a letter going through school. She was very smart, but she couldn't read all the time. So I had to kind of read for her.

And I just want to make sure that the confusion, if there's any confusion, especially when it comes to the Spanish language, that they understand that they're not doing something that they don't want to do. Here we fight for making sure that we decide that all of us can decide on what we want to do. It's not government trying to push us to decide that a person, I picture again, my mom, she makes that decision and she explains it to us as a parent.

Right, at the end, we have to make that decision, too with her. I just want to make sure that when it comes to language, anything that's being mailed out that that person, like my mom would understand, there wouldn't be any confusion. So it's more of a comment. Thank you, Mr. Chair.

And I appreciate your comment, Assembly Member. I think of my own community, and it's primarily Latinos. And our doctors are well versed with the Latino community. And I feel like that they, as long as many others, they want to make sure that they take good care of their patients. And so they either have a translator or they actually speak Spanish. And I'm sure this happens throughout the State of California as well.

I agree with you that we want to make sure that people understand what the vaccination is and the pros and cons of it. And I'll tell you, there's more pros. You can't convince me there's more cons on this. I'd love to share other stories, family stories, about this. I can't because I'll cry. I'm very fortunate that I sit in this seat and that I can help change someone's lives. And that's all I can say.

Thank you. Any other comments? I'd like to thank you, number one, for your persistence and number one, number two, for your mission to do this. I've been a believer in what you're doing from the beginning and supportive from the beginning, and this is a horrible virus. Many in the audience probably don't realize that more than 50% of the cancer from human papillomavirus is throat cancer. Probably the worst sore throat you could ever imagine and one that will kill you. I recognize you've come a long way.

This isn't exactly what you're looking for. None of us want to keep kids out of school, recognize the challenges that we face in, and certainly with what we saw during COVID. I support your bill, and I appreciate that, your statement of continuing to work with opposition throughout the process. This is the first Committee, and you've spent a long time. We've been talking about this for a very long time. My staff has worked with you for a long time, and we were happy to do it.

So thank you once again for bringing it forward. The bill does enjoy a do pass recommendation when we have a quorum and I'd like to give you an opportunity to close if you'd like.

I think to make it easy on myself without tears, I simply ask for your aye vote.

Thank you very much. And thank everybody, witnesses on both sides who came today. I appreciate it. Thank you.

Okay, Mr. Rodriguez.

Thank you, Mr. Chair and Members. Thank you for giving me the opportunity to present AB 40, which takes several steps to prevent ambulance patient offload delays to ensure ambulances are available to respond to 911 calls for emergency medical services. I would like to start by accepting the Committee amendments to require all EMSAs to establish an APOT standard of no more than 30 minutes. AB 40 would also require hospitals to develop an APOT reduction protocol and follow the protocols with EMSA.

As someone who spent over 30 years working as a first responder in the emergency medical services system, I'm all too familiar with wall times. Excessive wall times has been a problem for decades. In fact, I've personally waited over 12 hours at Emergency Department to transfer a patient to hospital staff. According to a 2020 EMSA report, each year, roughly 70,000 Californians wait over an hour on an ambulance gurney once they arrive at a hospital.

Not only do wall times result in untimely care for patients experiencing an emergency, but it prevents EMTs and paramedics from responding to other emergencies. In November 2021, EMSA convened a wall time task force. In June 2022, the EMSA Wall Time Task Force voted on 19 recommendations to mitigate ambulance patient offload delays. This Bill codifies some of the most important recommendations. With that, let me turn it over to my witnesses in support: Brian Rice, President of the California Professional Firefighters, and Sean Burrows, President of the Alameda County Firefighters Local 55. Thank you.

Good afternoon, Members of the Committee. My name is Brian Rice and I'm the President of the California Professional Firefighters. And I have the honor of representing nearly 35,000 professional firefighters, EMTs and paramedics statewide. I've also served nearly 30 years as a firefighter with the Sacramento Metropolitan Fire Department.

CPF is a proud sponsor of AB 40, and I would like to thank Assemblymember Rodriguez for his leadership on this issue. And I would also like to thank you, Dr. Wood, and your Committee and staff for working with us on this measure. Thank you. Dangerously long wall times have been a gathering crisis in the state's emergency response for more than a decade.

In January 2023, EMS crews were held on the wall in Sacramento county for 3267 hours, resulting in a cost of over $688,000 in wall time costs for just one month. That equates to 100 hours per day that units are not able to respond to emergencies just here in the County of Sacramento. When ambulances are stuck on the wall, they can't do their jobs protecting the public. That means longer and longer response times for other patients.

When seconds count, it can literally be a matter of life and death. This also creates a cost to the taxpayer by forcing firefighter EMTs and firefighter paramedics to effectively subsidize the staffing levels in hospitals while they wait to transfer patient care. In 2022, Anaheim Fire Department medic units held on the wall for over 5800 hours. This equates to two full-time staffed units in the ER in Anaheim every year.

CPF has worked for years to try to drive solutions that help alleviate ambulance patient offload times, and AB 40 is a necessary step to create accountability and drive reductions in wall times. As proposed to be amended, AB 40 will set a statewide cap of 30 minutes for ambulance patient offload time and direct each LEMSA to adopt a standard. As noted in the analysis, a significant number of local jurisdictions have adopted a standard of 20 minutes or less.

CPF will stand ready to work with all our local partners to ensure that adopted standards meet local needs and are in the best interest of patient care. AB 40 will also require hospitals to develop and implement a protocol to reduce offload times if they exceed the standard. Have hospitals struggled with Covid-19 and the increasing demands on healthcare system? There's no doubt about it, but this can't be an excuse to put an endless tap on taxpayer-funded emergency response system.

The health and safety of our community depends on fast, effective, fully staffed and available emergency response. This can't happen when ambulances are stacked in a line in the ER waiting to offload patients. For all these reasons, I respectfully request your support on AB 40. Thank you.

Good afternoon, Chairman Wood and Members of the Committee. My name is Sean Burrows.

I'm a 27-year veteran of the fire service and currently serve as a Fire Captain Paramedic for the Alameda County Fire Department, as well as President of the Alameda County Firefighters Local 55. As you have heard from Assemblymember Rodriguez and President Rice, ambulance patient offload time or wall time continue to grow and firefighters throughout the state are being pushed to the brink.

I'd like to highlight how ambulance patient offload times impact my community and the Alameda County Fire Department's ability for service delivery to provide to our residents. Excessive wall time impacts care for the patient waiting at the hospital and impacts the safety for the next patient experiencing an emergency and waiting on an ambulance. In many emergencies, one of our fire engines are first on scene to begin rendering patient care while waiting for an ambulance to arrive.

In my community, fire engines are consistently waiting on scene for an ambulance to arrive because zero ambulances are available in the system. Recently, an Alameda County fire engine waited on scene with a patient for nearly 90 minutes because there were no available ambulances. In many cases like these, not only is the patient impacted by not receiving timely emergency services, but the fire engine is also unable to respond to any additional incidents in our response area. These delays are not one-offs or anomalies.

They occur daily and happen throughout the state. AB 40 will direct the EMSA authority to enhance data collection, ensure that each local EMSA agency has APOT standards not to exceed 30 minutes and will require hospitals to develop protocols to reduce wall times if they exceed the LEMSA adopted standard. Reducing wall times directly benefits the patient and our residents. Would you want your loved one to be waiting for hours at an emergency department after being transported by an ambulance?

Or could you imagine experiencing a medical emergency and having to wait an hour and a half for an ambulance to arrive because all resources are tied up on the wall? It should be unimaginable because no Californian should have to experience a delay in emergency medical care. And for these reasons, we respectfully ask for your support on AB 40.

Thank you very much. Others in support?

Dr. Dan Haverty, I'm a Fire Chief for the Sacramento Metropolitan Fire District. We support.

Thank you.

Jon Rudnicki, Assistant Chief with the Sacramento Metropolitan Fire District. Support.

Mr. Chair, Members. Sara Flocks, California Labor Federation, in support.

Thank you.

Good afternoon. John Bagala, President of the Marin Professional Firefighters Local 1775. We ask for your support. Thank you.

Good afternoon. David Riles, Director, United Firefighters of Los Angeles. I'm in support.

Thank you.

Firefighter Paramedic Ryan Quigley with Los Angeles Fire Department, supporting firefighters and paramedics. We support.

Thank you.

Steve Adelman, representing the 3400 Members of the Los Angeles City Fire Department in support of AB 40.

Thank you.

James Michael Paulo with the American Federation of State County Municipal Employees (AFSCME) in support.

Thank you.

Shawn Ehrenberg, Captain with Stanislaus Consolidated Fire, as well as Union President for Stanislaus Firefighters Local 3399 also in support.

Thank you.

James Kornweibel, Vice President of Roseville Firefighters Local 1592, also in strong support.

Thank you.

Scott Longmire with Local 522 in support.

Thank you.

David Sprague, Berkeley Fire Chief, in support.

Thank you.

Keith May, Interim Deputy Chief in support, Berkeley Fire Department.

Steve Pendergrass, Hanford Fire Chief in support.

Thank you.

Austen Thomas with Santee Fire Association, and we're in support.

Thank you.

Cody Reddick, also with Santee Fire Department Local 4373, and we support.

Thank you.

Good afternoon. Kyra Ross, on behalf of the City of Coronado, in support.

Thank you.

Good afternoon. Felipe Rodriguez, Fire Chief, Cosumnes Community Services District Fire Department in Elk Grove and Galt in South Sacramento County. Full support.

Thank you.

Good afternoon. Jon Jordan, Battalion Chief representing the Santee Lakeside Emergency Medical Services Authority and in support.

Thank you.

Good afternoon. David Parsons, Fire Chief, City of Oceanside, San Diego County, strong support.

Don Butz, Fire Chief, Lakeside Fire Protection District, San Diego, county, in support.

Good afternoon. Chris Tubbs, President, California Fire Chiefs Association, in strong support.

Richard Pearce, Tiburon Fire District representing Fire District Association of California. Strong support.

Nate Pearson, Division Chief, Carlsbad Fire Department, San Diego County, in support.

Todd Holmes, President of Carlsbad Firefighters Locals 3730 stand in strong support.

Good afternoon. Chris Richichi, Anaheim Fire and Rescue. Strong support.

Dave Barry, Captain, Paramedic with Anaheim Fire and Rescue. Strong support.

Good afternoon. Graham Owen, Engineer, Paramedic for Cosumnes Fire. Also Local 522 member, strong support.

Good afternoon. Eric Jackson, Fire Paramedic and EMS Specialist for Cosumnes Fire Department and support.

Good afternoon. Kristin Thompson, EMS Division Chief with Newport Fire, in full support.

Good afternoon. Robert Brouwer, with Cosumnes Fire Department. Strong support.

Good afternoon. Priscilla Quiroz, on behalf of the City of Santa Monica, in support.

Robert Webber, Board of Directors for Sacramento Metropolitan Fire District, strongly support.

Andrew Ghali, Captain with the Hayward Fire Department and Union President for Hayward Firefighters Local 199, strongly support.

Mike Taylor, Deputy Chief, Sacramento City Fire Department, in support.

Jeff Neal, representing the City of Chula Vista, in support.

Freddy Escobar, Captain 2, UFLAC President representing 3400 brothers and sisters of UFLAC. We're in strong support. Thank you, Chairman and anybody in this Committee, please reach out to your fire department do a ride out and see what the men and women are going through every single day. Thank you.

Thank you. Anyone else? Is there opposition to the Bill? See no one. Are you tweeners or?

Thank you. Good afternoon. Vanessa Gonzalez with the California Hospital Association. We'd like to thank Assemblymember Rodriguez, Chair Wood and Committee staff for your work on AB 40. We appreciate Assemblymember Rodriguez agreeing to the Committee amendments to allow LEMSAs to set their standards locally. Pending review of the language, we believe this will remove our opposed unless amended position on the Bill.

Hospitals agree that ambulance patient offload delays are a problem that need to be addressed and we look forward to working closely with our fire and ambulance providers on reducing delays. Thank you.

Thank you.

Hi. Good afternoon. Chair Wood and the Members of the Committee. I'm Barbara Bond. I'm an Emergency Physician, also Physician Leader, Co-chair of the Physician Leadership Group for Sutter Health. And we support the California Hospital Association statements and appreciate all the work that Assembly Member Rodriguez and the rest of the Committee have done on AB 40. I just really want to make kind of a heartfelt statement that this is an important issue for us, too, as emergency physicians and anyone who works in an ER.

We don't want our patients sitting on the wall. We don't want any of this either. We all understand that this is, as we've heard today, an extremely complex issue in terms of capacity issues in our hospitals. And we, more than anything, want to be partnering with our LEMSAs, fire agencies, ambulance companies to reduce APOT. And I think our approach in doing that has been very successful.

Sutter Roseville has, by implementing an APOT Committee system wide for Sutter, we have reduced the wall times there from an hour and 42 minutes to 30 minutes. Other Sacramento has had similar improvements just by collaborating locally. So I think that's the majority of my comments. Again, thanks to you and thanks to the Committee.

Okay, we'll take those two as testimony. So anybody else, just I'm in between, or whatever you are.

Rose Colangelo, Sutter Health and I also want to support the comments made by CHA and Dr. Bond, and thank you for collaboration.

Thank you.

Good afternoon. I'm Heidi Velger. I am the Nurse Manager at Summit Emergency in Oakland, ABSMC, part of Sutter Health. And I do also want to support Dr. Bond's comments and by CHA and thank the team for their support and collaboration. Thank you.

Hi, I'm Larry Johnson. I'm the Nursing Director for Sutter Alta Bates in Berkeley and Oakland, and I support the comments made by Dr. Bond.

Thank you.

Good afternoon, Chair and Members, Connie Delgado, on behalf of the California Emergency Nurses Association, we had an opposed unless amended position. Look forward to reviewing amendments. Thank you.

Thank you.

Solana County Board of Supervisors in opposition. Thank you.

Dennis Lopez with the United Hospital Association. Would like to thank the Chair and the author for their hard work. We assume the amendments are fine. Thank you.

Kelly Ash, with Dignity Health. We were opposed uness amended, but we look forward to reviewing and thank you.

Good afternoon. Jonathan Clay, on behalf of Scripps Health. Figured kneeling is better here. We also have an opposed unless amend position, but we look forward to seeing the amendments, and we appreciate the hard work of the Committee. Thank you.

Good afternoon. Aaron Taylor, on behalf of MemorialCare Health System, also had an opposed unless amended position, and look forward to seeing the language in print. Thank you.

Thank you.

Alison Ramey on behalf of Kaiser Permanente, we also had an opposed unless amended position. Look forward to reviewing the amendments and thank you to the author and the Committee.

Thank you.

Nicette Short, on behalf of the Alliance of Catholic Healthcare, Adventist Health and Rady Children's Hospital, and like some of my other folks, appreciate the work of the author and the Committee and hope to remove our opposition when we see the amendments in print. So thank you.

Thank you.

Amy Blumberg with the California Children's Hospital Association. We were previously opposed unless amended. Thank the author and the Committee for the work and look forward to looking at the amendments.

Okay, thank you. Anyone else? So no one bring it back to the Committee? Questions or comments? Mr. Fong.

I'll be very quick. I just want to thank the author. He and I have had extensive conversations about this. Appreciate the amendments and happy to support.

Anyone else? So once again, I think thank you, Mr. Rodriguez, and your efforts on this. I know you've been working in this issue area for the whole time I've been in the Legislature, so I appreciate your perseverance on this.

Thank you for accepting the amendments and we'll continue working as things go forward. And thank you to your witnesses as well. Does enjoy a do pass recommendation when we have a quorum. We're now at 3 hours in search of a quorum. We managed to get past last week's record of 2 hours and 45 minutes and counting. So anyway, would you like to close, Mr. Rodriguez?

Yes. First of all, I want to thank Committee staff and you, Chairman Wood, for working with me and the sponsors as well on this very important Bill. Obviously, my background is EMS. This is a decades-old issue with wall times.

As I've stated in my opening, I've waited 12 hours in a hospital ER decades ago, and still to see this an issue in the pandemic, I think just highlighted the importance of this type of legislation to free up our first responders and put them back in service to respond to emergencies to protect us throughout the State of California. So with that, I respect the ask for your aye vote. Thank you.

Thank you very much. Appreciate it. Thank you. While you're there, you got another Bill?

Yes, I do. Once again, thank you, Chair and members. First, I want to thank Chair Wood and the staffor Laura for taking the time to work with my staff on the amendments. Thank you and accept these amendments. Thank you for allowing me to present AB 1180, which would remove the requirement for the EMSA Director to be a physician and create a new Chief Medical Officer position in EMSA.

The EMS community is much more expansive than just ER physicians and other EMS professionals, including paramedics, EMTs, firefighters, dispatchers, nurses, emergency administrators, and more. The duties of the EMSA Director span many areas of expertise. Both the current physician requirements, many professionals with applicable experience are automatically ineligible. We already know that a non physician can successfully run EMSA thanks to our acting Director, Liz Bassinet.

Acting Director Bassinet is not a physician, but rather an emergency management professional who, in addition to serving as EMSA's Acting Director, also serves as the assistant secretary with the Health and Human Services Agency, where she leads the coordination of emergency preparedness, response and recovery across all of HHS. She has led MSA since 2021, including through the height of the COVID-19 pandemic, and is widely respected by professionals across California's EMS system.

She clearly demonstrates that with the relevant qualifications, the directors do not need to be a doctor. However, emergency medical representation at EMSA is important, which is why this bill also creates a CMO position. Creating a CMO will ensure a licensed emergency physician performs the duties that truly require medical background and can provide insight and advice to the director. Furthermore, EMSA has already submitted a budget change proposal to create this position.

Broadening the qualification to become a director and creating a CMO will create a more dynamic, more prepared and more representative of IMSA. With me to provide testimony is Doug Subers, representing the California Professional Firefighters.

Thank you, Mr. Chair Members. Doug Subers on behalf of the California Professional Firefighters, the author did a great job of going over the issue. CPF is in support of AB 1180.

We do think removing the medical Doctor requirement from the EMSA Director will help broaden the pool of available candidates to pursue that position. We also think it is important to have a CMO to ensure that patient care considerations continue to be made at EMSA. In addition to supporting AB 1180, CPF is also supporting the discussion within the budget process, the trailer bill language and the budget change proposal to fund a CMO at EMSA, and for those reasons, we respectfully request your support. Thank you.

Good afternoon. Dr. Dan Haverty, Fire Chief, Sacramento Metropolitan Fire District, we support.

Thank you very much. Others in support.

Steve Pinegrass, Fire Chief, City of Anaheim.

Thank you.

Don Butz, Fire Chief, Lakeside Fire Protection District in support.

Thank you.

John Jordan, Battalion Chief, Santee Lakeside Emergency Medical Services Authority, in support.

Thank you.

Chris Tubbs, President, California Fire Chiefs Association, in full support.

Thank you.

Kristen Thompson, EMS Division Chief with Newport Beach Fire, in full support.

Thank you.

Richard Pierce, Fire Chief, representing Fire District Association of California. Strong support.

Thank you.

David Sprague, representing Berkeley Fire Department, in support.

Thank you. Anyone else? Is there opposition to this bill?

Thank you, Chair and members. Tim Madden, representing the California Chapter of the American College of Emergency Physicians. We have an opposed unless amendment position with the amendments that the author has accepted.

We wanted to thank the author and his staff and the committee staff for looking at our amendments, and I believe this removes our opposition and we'll do that once that's in print. Thank you.

Thank you.

Thank you. Kat DeBurgh, with the Health Officers Association of California. Also with an opposed unless amended. We want to make sure that the CMO position is protected and has the authority that they need to protect the health of all Californians and we look forward to continuing to work with the author should the bill passed today to make sure that that language is incorporated. Thank you.

Thank you. Anyone else? Okay, see no one. Bring back the committee for questions or comments. Any questions or comments? Seeing none. Mr. Rodriguez, your bill does enjoy a do-pass recommendation and you know, we don't have a quorum. So with that, would you like to close?

I respectfully ask for an aye vote.

Thank you Mr. Rodriguez. Seeing no other authors present, I'm going to take this opportunity to present two bills. Ask the Vice Chair to take over for me. Thank you.

Chairman Wood will be presenting AB 815.

Thank you very much, Madam Vice Chair. Provider credentialing poses administrative challenges similar to prioritization and provider directories, as health care providers can be subject to different criteria depending upon how many plans they contract with. This proposal would streamline the credentialing process for doctors and health plans by creating a board to certify credentialing entities. Rather than waste time on overly burdensome administrative processes, health plans can focus on ensuring its enrollees have access to an adequate network and providers can focus on providing medical care.

The amendments identify minimum standards and clarify that this bill only applies to doctors and surgeons. With me in support is the California Medical Association. I think they're coming. We hope they don't trip and fall and require medical attention here, but, you know.

Excuse me. Thank you, Mr. Chair--Madam Chair--Madam Vice Chair, Members of the Committee. Brandon Marchy with the California Medical Association. Excuse me. We want to thank the Chair for taking on this issue of modernizing and updating the delivery of care and making sure that we can cut administrative and redundant red tape where we can. Oh, my word. So we look forward to continued conversations with stakeholders and would respectfully request your aye vote.

Thank you. Are there other witnesses in support? Please come forward.

Ryan Spencer, on behalf of the American College of OB/GYNs, District Nine, and the California Podiatric Medical Association, both in support.

Good afternoon, Priscilla Quiroz, on behalf of the California Academy of Child and Adolescent Psychiatry, in support.

Izzy Swindler, on behalf of California State Association of Psychiatrists, in support. Thank you.

Thank you. Are there any witnesses in opposition?

Good afternoon, Chair and Members of the Committee. Kind of in a tweener position. We submitted our letter of concerns. So my name is Robert Boykin with the California Association of Health Plans. We applaud the authors, sponsors, and Committee staff for their work and intention behind this bill. Nevertheless, our members have reviewed the bill and we are not opposed, but we do have some minor concerns.

And while we appreciate the intent of AB 815, we must point out that center policies have been attempted in other states without the desired results. For example, the Oregon Common Credentialing Program was enacted in 2013. The program was intended to simplify the credentialing process, reduce burden on practitioners, and eliminate duplication. While there was a broad consensus that the concept of centralizing credentialing information has merit, they encountered significant challenges that made it difficult to implement a cost-effective program that would benefit all Oregon practitioners.

After years of trying and millions of dollars spent, they effectively ended their effort to create the program in 2020. Other technical concerns about the bill--about this bill--are well stated in the analysis, and we will work with the other parties involved to reach consensus on our questions and issues going forward. Thank you for your time today.

Thank you.

Madam Chair and Members, Stephanie Watkins, on behalf of the Association of California Life and Health Insurance Companies. I'd like to echo my colleagues' concerns. We appreciate the author and the sponsor reaching out early, and we've had some really productive conversations. Our intent is just to ensure that our member plans continue to have the ability to credential those physicians to ensure that we provide the highest quality of care for our member companies. So for those reasons, we look forward to continuing these conversations and coming to a positive resolution. Thank you.

Thank you.

Thank you, Madam Chair and Members of the Committee. David Gonzalez, on behalf of America's Physician Groups. I apologize. I didn't get here on time. We're actually in support and look forward to working with the author on some additional issues, but happy to be in support.

Thank you. Okay, seeing no other witnesses in opposition or tweeners, bring it to the Committee. The two of us, three of us, any comments? So I'll ask the author to close.

Thank you very much, Madam Vice Chair. We obviously will continue to work with the opposition. We have amendments that we are accepting--I didn't mention that earlier; my bad--and consider this a little bit of a work in progress, but understand the intent. It should be much simpler to credential providers rather than having to credential with every single entity out there. It's duplicative, it's wasteful, and it takes people away from doing what they really need to do, which is provide care to patients. So with that, when we have a quorum, whatever day that is, I would respectfully ask for an aye vote.

Okay. Thank you. And you do have another bill?

Yeah. I'm going to step aside and let Ms. Petrie-Norris present her bill. She's here?

She is here.

So--and I'll pick this up later.

Thank You. Ms. Petrie-Norris will be presenting AB 1338.

Push the little button there, if you don't mind.

All right. Okay. Thank you, Mr. Chair and Members pleased to join you this afternoon to present AB 1338. AB 1338 will help expand health equity, improve quality of life, and provide long term healthcare savings for medical recipients by adding fitness and wellness services to the list of pre-approved community supports under CalAIM. I want to thank the chair and Committee staff for working with my office and happy to accept the Committee's recommended amendments.

In 2022, the Department of Healthcare Services CalAIM program was implemented to improve the quality of life and health outcomes of MediCal beneficiaries by enacting broad delivery system, programmatic and payment system reforms. A key feature of CalAIM was the introduction of a new menu of community supports which offer a cost effective alternative to traditional medical services and can be used in lieu of existing MediCal benefits.

These benefits include services like medically supportive foods or housing supports and are designed to address the social determinants of health. Nearly two thirds of all MediCal recipients come from disadvantaged communities that are disproportionately impacted by health disparities. Communities like these often face significant barriers to accessing places and means to exercise due to cost, safety and lack of information about the benefits of exercise.

AB 1338 would bring equity to medical recipients by allowing them access to fitness, physical activity, or recreational sports programs so they can improve their physical and mental health. And importantly, the provision of these health and fitness benefits to MediCal beneficiaries isn't just a nice thing to do. Increasingly, in private insurance plans all across the state and country, these benefits are being offered to members.

And there's one big reason for that, because these benefits not only improve quality of life for members and long term health care outcomes for members, they also lower long term costs as well. So with that, really pleased to be joined by our witnesses. We have Francesca Schuler, who's the President of the California Fitness Alliance, and Cher Gonzalez, who is joining us from the American Diabetes Association.

Good afternoon, Mr. Chair and Committee Members. Thank you for extending us the opportunity to testify for AB 1338.

And I want to thank Assembly Member Petrie-Norris for her commitment on improving the health of Californians by authoring this Bill. I'm Francesca Schuler. I'm the President of the California Fitness Alliance. We represent a united voice of all fitness professionals in the state, 345 partner organizations, 3000 fitness centers that provide safe places for physical and mental activities for millions of Californians every year. And our mission is really to promote a healthy Californian by providing safe and equitable access to exercise for all.

That's why we're a proud sponsor of AB 1338, which would add a new medical community support to the list of approved services to expand access to physical activity programs, memberships and activities for medical recipients. Why does this matter? First and foremost, this Bill will improve the health of traditionally underserved communities by focusing on preventative benefits of physical activity.

The CDC notes that regular physical activity is one of the most important things you can do to reduce the risk of disease and improve both your physical and mental health. Unfortunately, underserved communities that make up the majority of MediCal recipients often face significant barriers to exercise due to cost or lack of information.

Nearly two thirds of all Medi Cal recipients come from marginalized communities that would benefit the most, as they are most affected by health disparities and chronic illnesses such as heart disease, diabetes, or high blood pressure. AB 1338 would encourage healthcare professionals to educate patients about the benefits of exercise and bring equity to medical recipients through this new proposed community support. Programs like this do work.

Medicare provides access to exercise memberships to seniors through their silver sneakers program. And a study completed in 2021 evaluating its impact found that total healthcare costs were reduced by 16% for participants versus non participants, and medical costs were reduced by 18% through reductions in inpatient costs. Hospital stays were also reduced. Today, 42% of the state healthcare costs go towards treating the top five chronic diseases, with an estimated 141 billion dollars in direct costs spent on heart disease, arthritis, cancer, diabetes, depression and asthma.

If increased access to exercise results in even a 1% reduction in health risk factors, it would cut per person annual medical costs from $183 to $103 and could save the state up to 135 million dollars a year. California needs to be proactive and innovative in its approach to preventative health, and this Bill is a strong step forward in improving the health of its residents, particularly in underserved communities. For these reasons, the CFA is pleased to sponsor AB 1338 and ask for your aye vote on this measure.

Thank you.