Senate Standing Committee on Health

The Committee Health Committee will come to order. The Committee Health Committee. The Senate Health Committee will come to order. Good afternoon. As we continue to welcome the public in person and via teleconference service, we're going to allow six minutes of in person testimony per side. You don't have to feel obligated to use that, but in individuals wishing to call in when we get to the call in portion, the number is 877-226-8163 with the access code 736-2834 and we will cap public testimony on the phones at 15 minutes total.

Today, we have 14 bills on today's agenda, two of which are on our proposed consent calendar, SB 783 with amendments, and SB 641 with amendments. Okay, Senator Ashby, if you don't mind just talking to me. All right. Well, then, let's get this ball rolling. Thank you so much and welcome. And you are here today presenting SB 408.

I am. Thank you so much for having me here in your office.

You're welcome.

That'll help them come down. You'll see.

A meeting, just us.

All right. We are here to present SB 408, and I'd like to start by thanking your incredible staff. And I know every Senator starts by saying that, but your staff has actually worked really hard on this bill with us, and I'm very grateful and so is my team. This is a complicated bill, but also like a lot of things that happen in this building, really important and meaningful work. So we're super grateful to your team. Thank you so much for all of your help, and we will absolutely be accepting the Committee's amendments with appreciation.

SB 408, as amended, will develop an enhanced funding model within the current STRTP program for intensive care and treatment programs for youth with acute trauma based needs. As of January this year, there were approximately 52,000 children in California's foster care system. Over 17,000 of those are youth between the ages of 11 and 17 years old.

Since 2014, California has been implementing the continuum of care to reduce the use of congregate care and focus on keeping children and youth with families or family like relations. Through the CCR, California required former group homes to convert into higher level centers with more treatment options, known as short term residential therapy placements, which we affectionately call STRTPs because it just rolls right off your tongue. Complex needs youth have needs that cross systems of care. We know this.

Educational, occupational, mental health, substance abuse, just to name a few. And so these facilities allow them to address those complex underlying needs while dealing with them in a trauma informed way. The current structure of the STRTPs are effective programs for some youth, but not all. And specifically, they have failed our most highly traumatized youth. So this is an attempt to fix that.

Unfortunately, many of the STRTPs are under equipped to provide the necessary services and statewide gaps that exist in serving the needs of children, youth and families with multiple co-morbidities or cross system needs, which I'm speaking to the two social workers in the legislature here, so I know you know exactly what I mean. The STRTPs can also deny a placement. This is a pretty big deal. If the child's needs are too great and we really need to close that loophole, we can't just say it's too hard.

As a result, foster youth with the highest and most complex needs are sometimes rejected from STRTPs. And then what happens is what we have all deemed unacceptable, they experience what we call overstays in shelters or overnight stays in inappropriate places like motels, county office waiting rooms, or even jail cells, which we saw recently in Sacramento. Let me be clear, none of these are appropriate places for children to be staying, no matter what traumas they're facing or what's happening in their life.

To address these problems, SB 408 will establish an enhanced version of the STRTP. This is the new piece that your team helped us put together here. We have coined that as an STRTP of four. It used to be of one, but if we allow it to go up to four, we think it will work better from a financial standpoint.

This will provide intensive stabilization, assessment, therapy and other direct services for highly traumatized foster youth before they have to transition to a more permanent placement so that they get the help they need on the front end to be successful. STRTPs of four will be small, no more than four bed facilities that will take in all youth who need placement. You don't get to say no and build upon existing standards to include additional onsite 24/7 staffing.

STRTPs of four will include dedicated care teams where youth can receive direct care from multidisciplinary teams, get assessed across multiple systems of care, and start treatment and stabilization services for up to six months before being discharged. STRTPs of four will also provide family services, including caregiver respite during the six month after care period to help support the family, stabilize the child. I want to be clear that STRTPs of four will be within the current licensing structure of STRTPs.

This is an enhanced service model, will no longer be a separate facility or a separate licensing. SB 408 will also create 10 regional health teams across the state that will go directly to youth in crisis and their families to provide diagnostic, assessment, direct care, and support. These regional health teams are multidisciplinary, trauma informed, and they prioritize referrals from child welfare, probation, and tribes. The regional health teams can also help youth at risk of entering foster care.

So there's a preventative component to this, which is critical for youth who are not already in the system. When children are removed from their homes and placed in the protection of child welfare agencies, we owe them the very best care and treatment that we can possibly provide in the State of California. For those youth with complex needs, too often we're retraumatizing them their very first place, and sometimes before they even reach their first placement.

SB 408 attempts to address these gaps in placement and services so that our highest needs youth can receive the treatment they deserve. To do nothing is to accept an unacceptable alternative currently in play, one that uses jail cells in place of treatment facilities. I'd also like to quickly note that my sponsors and I have met with and heard the concerns of opponents and also of my colleagues here on the dais and in other committees. We believe this bill, as amended, now addresses most of those concerns.

I want to thank you, Chair Eggman. You've been extremely helpful personally to me and to my team. And to my colleagues. Senator Menjivar, too, who's been very helpful and taken time out of her day to meet with me as well, multiple times on this bill. This bill is better because of you. I have two support witnesses with me, Chairman, if that was okay. This bill is sponsored by the California Welfare Directors Association. And so Amanda Kirchner, with CWDA is here, and Rosie McCool, with CPOC is here as well.

Thank you very much. Amanda.

Good afternoon, Madam Chair, and Members. Thank you so much for your work on this bill. Especially want to call out your Committee staff and the author staff as well. We do agree. We think we are moving in the right direction. This is a better bill. I want to say, since California implemented the continuum of care reform, child welfare and probation agencies have really struggled to meet the growing complex needs of our youth.

And unfortunately, in the last year and a half, we've really seen this as a crisis. At this point, as the Senator mentioned, no child should have to spend a night in a conference room or an Airbnb or a jail cell, because we simply can't find someplace else to put them.

And so SB 408 is going to address that by, as we said, creating an enhanced STRTP facility, no more than four beds with cross systems care really pulling in the multidisciplinary teams that can help us address their educational needs, intellectual disabilities or developmental disabilities, and particularly substance abuse. We find a particularly large need and not enough providers and services for our children who are struggling with those crisis.

It's important to note that in a recent survey of our counties, we found that over 1000 instances of children staying in inappropriate placements, whether that was between child welfare or probation. So to the extent that we can have an alternative where we can get them stabilized, where we can get them treatment and assessments and then hopefully transition them into a stable family like base placement, that is really what our goal is.

I also want to pull particular note to the 10 regional health teams that we want to create. This is important because about half of our kids are actually only in fee for service. They are not in managed care Medi-Cal, and so the ECM that is being rolled out through DHCS does not apply to them. And these kids really need that managed care aspect that we can offer because of the cross system complications.

I want to say that we are absolutely committed to working with the other stakeholders moving forward. We appreciate their comments and feedback and we appreciate your support. Thank you.

And then finally what the bill does is it helps us flip our funding model a little bit. Right now, if you have a complex needs child, you have to sort of get the services first and then be reimbursed for those services through the state. This would flip that model, get the money up front so that we can quickly get those services, get the kids stabilized, and then from there we'd be able to spend that money instead of having to wait. The current system is just very burdensome and time consuming.

Thank you very much. Next person, please.

Good afternoon, Chair and Members. Danielle Sanchez, on behalf of the Chief Probation Officers of California, pleased to be a co sponsor. I want to thank the Senator for her leadership on this and certainly to the Committee to you, Chair and your consultants for working on this. Probation chiefs, along with our child welfare partners and this legislature, have worked diligently to really develop the right types of supports, stability and safety for youth to thrive.

For the probation chiefs, we really view these efforts both as being able to best serve the youth who are in probation foster youth, but also how do we look at making sure we are preventing and mitigating youth from coming into the juvenile justice system. And so we think this has a multitude of really important key factors to it. Echoing the comments of my child welfare colleague, when we looked at the needs of probation supervised foster youth.

We know the level of acuity has risen around substance use needs, mental health, and the complex medical and mental health needs, all of which we see this bill as being an important factor in working on and addressing. We also believe that this measure, as previously stated, is really key in looking at immediate kind of stabilization, while we look at how best then to transition to more suitable and sustainable home based care.

I would just kind of also articulate that I think the timely access to funding and responses to youth in crisis in terms of how that funding model works and making sure that we can address the needs in very quick, immediate ways is important for the youth and stabilization.

So we see this as really an important part of a whole continuum of responses for youth in foster care, but particularly focused on how do we help those youth who are in crisis in better alternatives that really meet their needs. So for those reasons, we're pleased to work on this and ask for your aye vote today.

Thank you very much. Now it's time for anybody else wishing to express support to come forward, and just your name and organization and position, please.

Good afternoon, chair and Members. I'm Summer Stephan, San Diego's County's District Attorney, in support. Thank you.

Thank you.

Kelly Brooks, on behalf of the Board of Supervisors for Los Angeles and Santa Clara counties here in support.

Thank you.

Tiffany Whiten with SEIU California, in support. Thank you.

Thank you.

Jeff Neal, representing the Board of Supervisors in San Diego County and Contra Costa County in support.

Thank you very much. Now's the time for anybody speaking in opposition to this bill to come forward.

Good afternoon, Madam Chair and Members. Gregory Kramer, on behalf of Disability Rights California. We're in opposition to the bill as in print. We did receive the amendments this morning and agree that the bill is now moving in a more positive direction. Our folks have not had a chance to peruse the language in detail, but we generally agree that it is moving in the right direction. Simply put, DRC opposes any type of legislation that would expand upon institutionalization of youth versus community placements. And so, again, just really commend the Committee and the author for working on these amendments, and we look forward to continuing discussions. Thank you.

Thank you. Next person, please.

Good afternoon, Madam Chair and Members. Adrienne Shilton with the California Alliance of Child and Family Services. We are not opposed to the bill. We have expressed concern about the bill in print, but we're deeply appreciative of the author and the sponsors and the Committee for your work. We believe that this moves the bill in a positive direction, so we look forward to continuing to engage, and I think we're all aligned on the goals.

Thank you very much.

Good afternoon, Chair and Committee Members. My name is Jordan Sosa. Here on behalf of California Youth Connection. We're a youth led advocacy organization with the membership of current and former foster Youth. I first want to appreciate CWDA on hearing our concerns of the potential harm this bill could have to youth in foster care. We did receive the amendments this morning.

However, we do have concerns on available state data on how congregate care settings have benefit the safety and well being of youth impacted by the child welfare system. Also here, the concerns of CDSS rolling out the continuing care reform dashboard. With that, we are in continuing our position in opposition of SB 408. I myself am a former foster youth myself, and I was also placed in emergency shelters. I could tell you firsthand that I wouldn't be here in front of you if I didn't have the opportunity to be placed in a loving home. My siblings and I all got placed in different placements, and I can tell you firsthand we could not find safety and loving homes and stability in institutions. Thank you.

Thank you very much. Now just name a position, please.

Ann Quirk, Children's Law Center of California, representing children in the dependency system in Los Angeles, Sacramento and Placer counties. We did submit a letter of concern, and I just really want to thank the Committee for all the work on this, as well as Senator Ashby and the co sponsors for willing to work with us and listen to us. We did just get the amendments this morning. They seem to address most of our concerns, and I really appreciate that and look forward to continuing to work with you on it.

Thank you very much. Okay, now it's time we go to the phones to see if anybody wants yes or no. And now this just your name, affiliation and position on the bill. Moderator, are you there?

I am. Ladies and gentlemen, if you wish to make a comment in support or opposition, please press 1. We'll be going to line 113. Please go ahead.

Nicole Wardelman, on behalf of San Bernardino County and the children's partnership in support.

Thank you very much. Next caller, please.

Next, we're going to line 117. Please go ahead.

Madam Chair and Members, Paul Yoder, on behalf of the Board of Supervisors in Humboldt, Fresno, and Kern counties, as well as City and County of San Francisco in support.

Thank you. Next caller, please.

And next, we'll be going to line 115. Please go ahead.

Good afternoon, Chair and Members. My name is Clarissa Peña with California Youth Connection, and I'm calling in opposition of SB 408.

Thank you very much. Next caller, please.

Next we go into line 123. Please go ahead.

This is Jenny Pokempner from the Youth Law Center. We oppose the bill as it's currently written, but we look forward to considering the amendments and appreciate the efforts of the sponsor and the Committee. Thanks.

Thank you. Next caller, please.

We'll be going to line 104. Please go ahead.

Good afternoon, Chair and Members. My name is Mercedes Parker. I'm a community advocacy coordinator with California Youth Connection, representing the Sacramento chapter. And I'm calling in opposition of SB 408.

Thank you. Next caller.

Next, we'll be going to line 118. Please go ahead.

Hi, thank you. Tricia Moreno-Gonzalez, on behalf of the community, sorry. The California Council of Community Behavioral Agency supportive of the amended direction of the bill. Thank you.

Thank you. Next caller, please.

There are currently no others in the queue, Madam Chair.

Thank you very much. Now would be the time we'd bring it back to the Committee. Any questions, comments, Senator Menjivar?

Madam Chair, if it's okay with you, could I turn some of my questions to the witness?

Yes.

From the county. Thank you so much. I've been able to dive into this realm through my sub three lens, getting a lot of exposure to these entities. Just a couple of questions I have, and I appreciate the amendments the author made with the Chair here. It is in the right path. I still have just some hesitancy.

I'm wondering if you could share with me how counties are approaching just some of the funds that's been available to address and create, for example, the Children's Crisis Continuum that addresses what I thought addressed some of the concerns and issues that it's been brought up today. There's a lot of funding that hasn't been pulled down by the county.

Sure. Happy to. I'll take your first question. So it's my understanding that it's been very difficult to pull down those funds at the county level, even though the funding is available. We haven't gotten things necessarily approved through the state.

If you could just dive into a little bit more on that and then also explain a little bit more why STRTP plus ones aren't the ideal approach or why that program isn't being implemented.

Okay.

And so counties have been hesitant to sort of ask for things when they've already been denied. And so for the complex needs youth, that's part of the reason we're trying to flip the funding model so that it's not reimbursement based, it's more upfront grant based, because we have had such problems pulling down the child specific funding and some of the other types of funding.

I'm sorry. The second half, she wanted you to talk about the plus.

In terms of the funding coming up front, Madam Chair, maybe you can also help me out here. Is there concern in the oversight? We're providing that before the service. It's hard to claw back the money once it's out the door. So that's also a part where.

No, I appreciate your budget, head.

Absolutely. No. And we would be happy to put in reporting requirements. We also know that we also have auditing requirements through both our Medi-Cal services, but also the reports that we have to do under child welfare back to DSS. We're also hoping that we can build in some reporting requirements for our STRTPs so that we can actually see how well they are functioning and the rates at which kids maybe aren't being taken into care or are, unfortunately, being ejected for any number of reasons. I know that you were concerned about some of the data aspects in human data.

The data, yes. And I don't want to monopolize the budget. This is a policy Committee. Let's focus on the policy. But it kind of, like, ties in together. And I have other questions. So we can dive into the second one right now.

Sure. Yeah no problem. And that was on the STRTPs of one. Correct? So one of the things about.

Well, that's the one you said that was hard to apply for because the money you get denied.

No, I'm sorry. I want to make sure I'm clear. The child specific funding that you're asking, why we don't see to draw that down and the counties aren't able to spend it. That's part of why it's difficult.

That's the crisis continuum.

Yeah. So for STRTPs of one, they aren't something that we can just roll out very quickly. They can take months to actually get set up. And additionally, they are very expensive. I actually recently just heard of one that was being set up at $120,000 a month, and that is not anywhere near where our normal STRTP rates are right now. We're in those conversations to have that be addressed. But these can be very expensive. It takes months to get them set up, and they're child specific.

Can you explain a little bit more? I mean, the math for me, if one is expensive, then four is going to be really expensive.

And so that's great for one child, but it doesn't solve the overall need for all of our complex needs, youth. So that's why we are hoping to have something a little bit bigger. Up to four beds so that we can sort of have an economy of scale and build it up.

So part of the reason that it's expensive is a one off. If we have a four bed facility where all of the staff and the treatment options are already built in, it becomes an economy of scale because they're already going to be there offering all of those things, whether it's for one child or up to four child, instead of trying to create it kind of on the fly just for one kid as they come up and needed throughout this.

That, for me, worries me, because we're moving towards a child specific plan. And you just said the child specific approach is not working. We need to bring in four, so we're not going to be child specific. And some of the concerns of the opposition is that we need that we need child specific. We can't have an umbrella for four children and have a plan for four children.

I don't think that we disagree with that at all. And I think that's part of our concerns with STRTPs overall, is that when we moved out of the group home model, we really condensed about 12 to 14 levels of group homes and their needs into one overall STRTP model. But what we found over the last few years is that one size does not fit all.

And we are having a really hard time for these small populations of youth to make sure that they are getting all of the treatment and support services they need when they cross the multiple systems. We have a hard time pulling in Regional Centers, we have a hard time pulling in education. Sometimes substance use is a big problem.

So to the extent that we can have it be a very small child specific funding in a model that lets us not have to do this as a one off every time, calling the state for technical assistance, trying to pull together experts, we're on these calls sometimes once a week, if not more, because we're coordinating with multiple people all over the place.

Okay, thank you for that. And then one of the last ones are in the analysis, and I brought this up in the first Committee hearing, the analysis. I'm not going to disagree that this is a crisis like it is. Right.

That's why we're trying to build in the regional health centers, health teams on top of that, so that they can be an expertise level that's always there to help direct that child specific care.

We're seeing children in places that they shouldn't be that is the issue, and it's been the issue for years. But my predecessors, legislators before looked at that and said, this is an issue, so let's implement some programs. And this was like, back in 2021. And just last week, I got a funding request to even start that program, which was passed in 2021. And I'm wondering if the issues we're looking to address now. The program was passed two years ago through other legislation.

We just haven't given it time to address it. And once it starts, it will address it. Concern is departments have been given direction on these programs. They're set to be working. The intent is for them to work. And here comes, I know, within the same vehicle of STRTPs, but it is something else that's a continued concern I have, even with amendments.

So if I could just say in 2018, the Legislature passed AB 2883 from Assembly Member Cooley that directed the state and local counties and other government entities to come together and really figure out the gaps in the complex needs of care. And so that was passed in 2018. Guidelines were set up. There was a report due to the Legislature, but unfortunately it got delayed by Covid, but that was recently published in January of this year.

And one of the things that it says is that even with the programs that we have created, we still have these siloed programs and funding mechanisms that do not fill all the gaps.

But how do we know that if the program hasn't even started?

It's based on. No, absolutely. DSS bases on the available data that they have, on what they're rolling out and what they know is in the pipeline. And I want to make sure, I'm sure on which one you're referring to.

Issues. Programs like the psychiatric residential treatment facility.

Sure. So the PRTFs don't actually meet all of the needs that we're talking about for these kids. That's a very specific form for kids having an acute mental health crisis where they can step down out of hospitalization or as an alternative to hospitalization, but it doesn't necessarily meet all of the other needs that they might have around, like eligibility, education, or Regional Center needs.

I know other Members have here, so I can't no longer monopolize the conversation. My colleagues.

Thank you very much. Anybody else having questions on this topic since Senator Menjivar has been doing? Yes, please.

Thank you very much.

Thank you, Madam Chair. And I apologize. I'm bouncing between committees like all of us are. I just want to thank you for introducing this piece of legislation. You know, these foster kids, it's not their fault that they're where they're at, and so they shouldn't be punitively punished for it, especially those with severe issues that need to be addressed. A little love goes a long way. And so I just want to thank you for bringing this forward, and I look forward to supporting the Bill, and I'll move it when appropriate.

Thank you. That's noted. Yeah. And so thank you very much for taking the amendments. And, Senator Menjivar, to your points, we've worked a lot on this bill, and it was a very big bill, very ambitious, and nobody denies the problem that we're all trying to fix.

I think some of the hesitation is the work this Legislature has done to put programs in place that are still rolling out, and if we continue to just pile more things on top, then nothing has a chance to roll all the way out. So, that being said, it has been pared down not to create a whole new licensing scheme, but just be able to provide that services through the financing mechanism to be able to be more nimble with that.

And that's as you understand it.

Right.

It is how I understand it, and I really appreciate that. And I would just also ask that folks remember that this guidance is not coming from your new freshman colleague. This is coming from all of your child welfare directors across all of your counties. They're in complete, unanimous opinion on this. So I know there are some outside interests that have some concerns about what we're doing, where we're going.

But your welfare directors, your county Casas, your county probation officers, your county DAs, they are 100% aligned because of exactly what Senator Grove said. They don't want to see young people in inappropriate placements. And I don't have to tell anyone on this dais how hard it is to move even just a couple of feet to the left in the Legislature or in state government. It's challenging, but I think this is necessary.

The bill is much better today than it was even a few weeks ago because of the input of folks along the way. I'm sure it'll be even better by the time we see it on the floor. I urge an aye vote, and I thank you very much for your time.

Senator, if you were the only one bringing this, it would still be beautiful. You alone sponsoring it? Yes.

They do this every day, all day, every day. So I want to give them the support and help they need.

Thank you very much, and we'll take that as your close. Okay. Senator Grove.

Just a quick question. Can I ask another?

Okay, let's go.

I was almost off.

I know I know.

Senator Grove.

She wanted to monopolize more time.

She likes me.

She likes you. I just wanted to comment on what you just said and how it takes a lot to make the Legislature move further to get this done. But if they all turn to page seven on the analysis of 83 in 2022. Just last year, 2022, the state's child welfare agencies received 440,212 reports of abuse or neglect. Of these 51,806 reports in one year, one 12 month period contained allegations that were substantiated.

And 19,953 children were removed from their homes and placed in foster care via CWS system. So with all of our children hurting in this space, and there's data from last year, then we have to do something. And I am not advocating removing children from their home or anything like that. That's not my intent. But if children are being abused and hurt and punished, something needs to be done. And so. Thank you.

Thank you.

Senator Menjivar.

That's true. 100% true. I feel like we've done something. We haven't let it grown. But I'll leave that. I think I've beat the horse to the ground on that. My last question is, and maybe this is for you, too, Senator, is do you feel that it's 100% needed, that you need the funding up front to create the STRTP plus fours?

Let me answer that. I have no doubt. And also, let me just tell you, in the child welfare system, and this is something that your staff has doubled down on here, they have to get a license first. That means they've been pre approved to do this work. They already have acquired a license to work with this population. What you're asking them to do is now move forward. And we've tried for a couple of years here to ask them to just seek a reimbursement.

And what that has gotten us is kids in jail cells and kids sleeping in conference rooms, and that's not working. So maybe it would help you to think of it this way. This is a tweak to something this Legislature worked really hard on, and that is good work. But there's a piece of it that's not working. And your welfare directors are coming to you saying that piece isn't working.

Please allow us to make this change so that we can address these thousands of kids that Senator Grove is talking about. That's what this legislation does.

Thank you.

Thank you. And again, nobody is arguing that the best care of our kids is most important. I think what Senator Menjivar is saying, and what some of us feel is that some of the things are still rolling out. And if. I do not want to trivialize this at all, but it's like me starting to make dinner and my daughter coming home and saying, I'm hungry.

I want to make something now and then starting on top of it, so we never get to the meal, because we're always starting something else and never get to the finished product of what we're trying to do is reform the system. So, with that said, would you like to close again and from the future, after somebody closes, we don't go back, but we don't have a quorum yet.

Chairwoman. I just would say I agree with you 100%, and I have worked in this space in the past in my life, and I think what's great about this is that we're trying to be proactive. I'm actually really proud of this Legislature's work prior to me getting here. That's very obvious. And I think this program worked really well. And the idea of taking this and embedding it in the existing program, I think, answers that question. So I urge an aye vote Again, thanks.

And when we have a motion by Senator Menjivar, and when we have a quorum.

You have a motion from Senator Grove, I think.

Oh Senator Grove, thank you very much. And when we have a quorum, we'll take the vote.

All right. Thank you very much for your time.

Thank you very much. Okay. Senator Portantino. Okay. We are doing SB 427 today.

Yes, we are.

You've already showed us your folder.

Thank you. I do have a folder. I'm equipped. Thank you, Madam Chair and Members. SB 427 will eliminate cost sharing and reduce access barriers to PrEP and PEP in health insurance coverage. The HIV epidemic continues to disproportionately impact historically disadvantaged communities in California. African Americans are the most disproportionately affected by HIV, making up 17% of California's HIV positive population, but only around 6% of California's total population.

Latinx people make up the largest racial ethnic group among new HIV diagnosis, accounting for 50% of all new HIV diagnosis, but again, only 40% of California's population. SB 427 would eliminate cost sharing for PrEP in grandfathered health plans, eliminate cost sharing for PEP in both grandfathered and non-grandfathered health plans, and require health plans and insurers to supply injectable PrEP and PEP directly to providers who administer the drug to patients.

The Bill will also address unnecessary burdens and utilization management methods used by insurers to allow people to access non-formulary or non-generic drugs when a provider determines that an alternative drug would be safer or more effective per patient. This afternoon I have to testify, Katie Fisher from the California Department of Insurance. The Insurance Commissioner is the sponsor of the Bill, and when appropriate and when there's a quorum, would respectfully ask for an aye vote.

Thank you very much, Senator. Please go ahead for a supporter.

Good afternoon, Madam Chair and Members, I'm Katie Fisher. I'm an attorney at the Health Equity and Access Office of the Policy and Legislation Branch at the Department of Insurance. I'm here today on behalf of Insurance Commissioner Ricardo Lara. First, I'd like to thank Senator Portantino for authoring SB 427. Commissioner Lara is a proud sponsor of this Bill. As the Senator already said, SB 427 would eliminate barriers to HIV pre-exposure prophylaxis, or PrEP, and HIV post-exposure prophylaxis, or PEP in health insurance coverage.

PrEP is a drug that an HIV negative person takes to remain HIV negative, and PEP is a drug that, if taken within 72 hours after potential HIV exposure, will prevent HIV infection. As the Senator made reference to, in California, there are close to a million people still in grandfathered health insurance coverage, but their health insurance does not have to cover PrEP without cost sharing. SB 427 would eliminate cost sharing for PrEP in grandfathered policies. Currently, PEP does not have to be covered without cost sharing.

Cost should not be a barrier in urgent situations where PEP is urgently necessary. This measure would eliminate cost sharing for PEP in both the grandfathered and non-grandfathered markets. To ensure that PEP access continues to be available at smaller clinics with limited financial resources, SB 427 would forbid insurers from requiring clinics to pay for these drugs upfront. Instead, it would be covered through the outpatient prescription drug benefits. This measure, also, this is slightly technical, will still allow insurers to use formularies, but would require insurers to create a pathway for people to get coverage for a drug that is not already otherwise listed on their insurers formulary. SB 427 would expand access to $0 PrEP in California while similar coverage is in peril throughout the nation, in this country, due to the Braidwood decision, which I'm sure you're familiar with. It's inherent that it's very important that we lead the way and expand access for coverage for all. On behalf of Insurance Commissioner Ricardo Lara, I ask for your aye vote.

Thank you very much. Anybody else speak in support of this today? Now's the time to come forward. Name and affiliation, please?

Thank you, Madam Chair. Cher Gonzalez, on behalf of the Hemophilia Council of California, otherwise known as HCC, in support.

Thank you.

And Craig Pulsipher, on behalf of Equality California, in support.

Thank you.

Good morning. Lindsay Gullahorn, I'm sorry. Good afternoon. Lindsay Gullahorn, on behalf of the California Community Pharmacy Coalition, in support.

Thank you.

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

Thank you very much. Anybody speaking in opposition to this Bill today? Now's the time to come forward. Welcome.

Good afternoon, Madam Chair, Members of the Committee. Jedd Hampton with California Association of Health Plans, representing 43 Knox-Keene licensed plans covering approximately 28 million Californians. Regrettably, we are opposed to SB 427. I would like to thank the author's office and the sponsors for the open dialogue we've had on this Bill to date. But ultimately, we are concerned that this Bill would require health plans to cover all PrEP and PEP drugs, devices, and products without meeting critical medical necessity criteria.

We are also concerned that this Bill removes cost sharing, all cost sharing for prep and pep drugs, devices, and products. The CHBRP analysis, the California Health Benefits Review analysis, has pegged the premium impact on this Bill to be approximately $157,000,000 in increased premiums. As an industry, we are looking at all of the mandate bills, all 23 mandate bills that were introduced this year, and looking at them holistically.

And in fact, CHBRP this morning released a letter indicating the premium impacts for the 18 bills that they analyzed this year, and they pegged the premium increases to be at approximately $1.28 billion in premium increases this year. So for these reasons, we are opposed to the Bill. Thank you.

Thank you. Steffanie.

Steffanie Watkins, on behalf of the Association of California Life and Health Insurance Companies. I'd echo my colleague's comments. I think our concern also revolves around the deletion of medical necessity. We'd like continued conversations. It's the second Bill we've seen in the last couple days, and given the fact that that's ubiquitous through our codes, it's what we always use to determine the standard for which care is delivered. I think we'd like to have some conversations to better understand that. So thank you.

Thank you very much. Anybody else speaking in opposition to this Bill? Now's the time to come forward. Just your name and affiliation, please.

Thank you. Preston Young from the California Chamber of Commerce here in opposition because of the premium impact. Thank you.

Thank you very much. Now we'll go to the phone lines. Moderator, if there's any calls on the line for for or against, it's name and affiliation and your position on the Bill.

Ladies and gentlemen, if you wish to make comments, support or opposition, please press 1 then 0. We'll be going to line 125, please. Go ahead. 125, your line is open.

Next we'll be going to line 19. Please go ahead.

Hi there. John Drebinger, founder of Equity Centered Communications and strong support of the Bill. Thank you.

Thank you very much. Next caller, please.

Next, we'll go into line 98. Please go ahead.

Sandra Poole, Western Center on Law and Poverty and support.

Thank you. Next caller, please.

There's currently no one else in the queue, Madam Chair.

Thank you very much. Now would be the time we'd bring this back to the Committee. If there's any questions on the dais. Okay. We don't have a quorum here for a motion, but I'll just say thank you for working with the Committee on this, and I certainly hear the plans, and I certainly share the concern about the continued mandates and the cost sharing. And it's a system we live in right now. And we'll have to continue to have these conversations, and I'm hoping you'll continue to have conversations with the opposition. Thank you very much. Would you like to close, Senator?

I would. And I would like to just make one comment upon the medically necessity piece. Preventive medicine is never subject to the medically necessary standard because by definition it's preventive. It's reacting before the emergency, and so it's just not subject to that as a General policy. So obviously we will continue to have conversations. It's an important thing to do, and I respectfully ask for an aye vote when appropriate.

Thank you very much. And you have another Bill before us today, SB 551.

I do, and I would like to begin by accepting the Committee amendments outlined in the mockup and thank your Committee staff for working with my staff to get SB 551 to where it is right now. It would enhance collaboration between counties and local education agencies, ensuring that mental health boards, including representation of youth and education leaders, all work together.

With the amendments in the mockup, SB 551 would require that at least 20% of members on a mental health board be employed by a local education agency and at least 20% be 25 years of age or younger. This will be in counties with a population of 500,000 or more.

In counties with a population fewer than 500,000, but more than 100,000, SB 551 would require at least one member in each of these categories, and in counties with populations below 100,000, the county would be required to give strong preference to at least one in each of the categories.

Lastly, 551 requires that no more than 49% of members on these boards own or operate an organization or business with a financial interest, and the Bill will help address the dire state of our children and youth's mental health crisis. I know that's something that the Chair cares deeply about, and there's lots of efforts in this continued space. So obviously our goal today is to keep the Bill moving, to be relevant to the conversation.

And we have with us Dr. Mary Ann Dewan, the Superintendent of Santa Clara County schools, and Dr. Michael Romero, the Chief of Transitional Programs for L.A. Unified, to testify in support.

Thank you very much. Welcome. Please begin.

Thank you. It's a pleasure to be here. I'm Dr. Mary Ann Dewan, Santa Clara County Superintendent of Schools. We're pleased to sponsor Senate Bill 551 in partnership with CTA, LAUSD, the California School Boards Association, and the California Association of School Psychologists. My appreciation to Senator Portantino for bringing forward this really essential Bill that prioritizes youth mental health and wellness. As we all can agree, youth are facing a health and mental health crisis.

Intentional self-harm among 13 to 18-year-olds has increased by 91% and overdoses have increased by 95%. Diagnoses of major depressive disorder have increased by 84%. Yet access to mental health services to youth has declined. The Mental Health Services Act requires counties to spend 51% of prevention and intervention, or PEI, funds, on children and youth, but nearly all counties struggle to meet this threshold. According to the Mental Health Services Oversight and Accountability Commission.

Currently, most MHSA funded programs do not focus on children and may only reach a small number of individual youth. In addition, the vast majority of counties currently have no youth or public education representative on their mental health board.

And despite children and youth being an identified priority in Proposition 63, this lack of representation is one of the causes of concern that leads to underinvestment in children and school-based services, which has compounding effects as children experiencing trauma grow into adults that had no access to prevention and early intervention services.

School-based services, including wellness centers, will be key to meeting our students' needs, and this Bill would help address underrepresentation of youth interests by ensuring that county mental health boards, which are responsible for reviewing and helping to create the county's three-year mental health spending plan, include youth and public education representatives. I urge you to join my office in supporting Senate Bill 551 and respectfully request your Aye vote.

Thank you very much. Next witness, please.

Good afternoon. Chair Talamantes Eggman and Members of the Committee. I am Dr. Michael Romero, Chief of Transitional Programs with the Los Angeles Unified School District, and here to testify as a co-sponsor in support of Senate Bill 551 by Senator Portantino.

In 2004, voters passed Proposition 63 the Mental Health Services Act, or MHSA, and Proposition 63 allocates 20% of its funding in each county for prevention and early intervention and states that 51% of those funds shall be used to provide services to children and youth. SB 551 seeks to revisit the MHSA's intent of providing essential mental health funding for youth-based services and interventions. It strengthens the critical collaboration between counties and local educational agencies, or LEAs.

In the nearly two decades since the MHSA's inception, county mental health boards developed entrenched memberships that does not reflect all of the needs of those the Proposition originally intended to serve, including youth 25 and younger. It is for this reason that SB 551 requires youth membership and membership of school employees on mental health boards in large counties.

In our case, L.A. Unified may only be one of 80 schools districts in L.A. County, yet we represent 40% of county students and are the second-largest school district in the nation. L.A. Unified serves as a national leader in the investments and delivery of school-based mental health services. In 2019, we launched a one of its kind early childhood mental health program, the Trauma and Resilience Informed Early Education Program.

This program utilizes a prevention model to increase protective factors and reduce risk factors for children and families in our early education centers across our district. This program is one of many that L.A. Unified provides as an opportunity to support the parents and caregivers of our youngest learners, but it is based on one-time funding and is not sustainable without the ongoing investments of California.

Leveraging Prop 63 funds to better meet the mental health needs of youth 25 and under is critical while the state continues its implementation of the $4 billion Child Youth Health Behavioral Initiative. Our expertise and the expertise of LEAs in California is vital to the ethical oversight of these mental health dollars that can better support the needs of our youth. Los Angeles Unified is pleased to co-sponsor SB 551 and we thank you for your commitment to student wellness. Thank you.

Thank you very much. Now would be the time for anyone else wanting to speak in support just to come forward and give your name and affiliation.

Good afternoon Madam Chair and Members. Oussama Mokeddem on behalf of Public Health Advocates, in support. Thank you.

Thank you.

Good afternoon Chair, Members. Blake Johnson on behalf of the state Superintendent of Public Instruction, Tony Thurman. Proud co-sponsor here in support.

Thank you.

Madam Chair. Toni Trigueiro on behalf of the California Teachers Association, one of the co-sponsors, so thank you for your support.

Thank you very much. Okay, now we'll move to any opposition for the Bill. Please come forward.

Hi, Theresa Comstock with the California Association of Local Behavioral Health Boards and Commissions. We have requested changes, and I understand there have been some, but it doesn't sound like it's still doable for our boards and commissions. They have a lot of requirements already to be understood.

We have requested that a portion be deleted that includes at least 20% of total membership be employed by a local educational agency, and at least 20% shall be an individual who is 25 years of age or younger, because that actually equals 40%, and that does not represent the demographics of a community. So we have asked for these amendments, and I guess at this point we had taken a support if amended position.

We asked that instead of that requirement, that it be replaced so that counties with a population of 100,000 or more, at least one Member of the board be employed by a local education agency and at least one individual be age 25 years or younger. Thanks.

Thank you very much. Next person speaking in opposition.

Good afternoon. Lisa Gardiner with the county Behavioral Health Directors Association. We have an opposed position along with a coalition of providers and others on the Bill in print. We are very appreciative of the work of the Committee and the amendments. We are continued to review them and thank the author and look forward to further engagement. Thanks.

Thank you very much.

Good afternoon. Sarah Dukett, on behalf of the Rural County Representatives of California, opposed unless amended. I want to thank the author for the amendments. We're still concerned about the threshold for rural jurisdictions in what's considered small. Looking forward to working with the author.

Thank you, Sarah.

Kelly Brooks. Kelly Brooks, I'm here on behalf of the urban counties of California and the California State Association of Counties. We submitted an opposed letter. Want to thank the Committee staff and the author for taking the amendments today. We're still reviewing them and look forward to continuing to work on the Bill. Thank you.

Thank you very much. Now we'll go to the phone lines. This would be the time for people speaking for, and, or against. Just name and affiliation and position, please.

Ladies and gentlemen, once again, if you wish to make a comment in support or opposition, please press one then zero. We do have a couple that have queued up. One moment while they're given their line number.

We were going to line 128. Please go ahead.

Madam Chair and Members. Laura Wasco with the California Association of School Psychologists, a co sponsor on the measure, and Orange County Department of Education Superintendent Al Mijares in support of SB 551. Thank you.

Thank very much. Next caller, please.

We'll be going to line 129. Please go ahead.

Hi, Leticia Garcia, on behalf of the Riverside County Superintendent of Schools in support.

Thank you. Next caller, please.

There's currently no others in the queue. Madam Chair.

Okay, thank you very much. That'll be the time we'd bring it back to the Committee for any comments or questions. Senator Roth?

Madam Chair. I just want to thank the author for bringing this measure forward. Obviously, we're all interested in making sure that young people have the care and the services that they need, those with mental health issues.

I think the comments that we've listened to this afternoon highlight the problem, which is we have a bucket of funding, and it's Prop 63, and that bucket of funding has a top and a bottom, and we continue to add requirements on that bucket for the behavioral health folks in our counties and otherwise, and it points to the need for more money. We'll figure that out and we'll continue to work that. I know our chair is laser focused on that. So with that, I'm pleased to support the Bill.

Thank you, Senator Ross. All right, Senator Porntino, thank you very much. Thank you for taking the amendments. Thank you for your attention and interest in this really important topic. And I'm sure you'll continue to work with the opposition on the numbers of the details, but I certainly understand your intent. Would you like to close?

Thank you. And respectfully ask for an aye vote?

Thank you very much. And hopefully when we get more Members here, we'll get a motion and we'll take a vote on that. And we thank you, Senator Caballero. And I think you're going to be here with us for a little while.

Brought my lunch.

Alright. Got your lunch. Got some snacks, and dinner too. Maybe. I don't know. I was here till midnight last night, so I'm prepared. We do not intend to do that on the Health Committee.

Very good. I understand. I'll talk fast. So thank you, Madam Chair and Members, I'm pleased to present it's file number four, SB 524, which will allow pharmacists to provide direct treatment to patients following positive tests for a select number of common, easily treatable diseases. I would like to thank the Committee's assistance with drafting the amendments before you today. And I'll be accepting the amendment that removes STIs from the list of diseases that can be treated pursuant to a clear wave test.

Healthcare, as you know, is inaccessible for many Californians, especially in rural California. Rural residents are confronted by many obstacles, including a shortage of physicians and primary care providers, lack of transportation, hospital closures, and limited access to treatment for various viral illnesses. Many rural Californians face expensive emergency room visits as their primary care facility or long waits in order to be treated for diseases like Covid-19 or strep throat.

The limited number of healthcare facilities serving rural areas are often burdened with more patients than they have the capacity to serve. This was particularly the case during the recent tripledemic of COVID, influenza, and RSV. Nearly nine in 10 Californians live within 5 miles of a community pharmacy, and the role of the pharmacist is in orchestrating patient care is underutilized for many patients.

Community pharmacies can provide a quick primary access point to healthcare, and quite frankly, people use their pharmacists as a way to go by and get information about ways to treat really common types of illnesses and injuries. Two years ago, I authored a Bill that allows pharmacists to perform several FDA-approved or authorized tests, allowing pharmacists to screen for COVID-19 and several common illnesses. However, pharmacists cannot currently prescribe treatment for common healthcare conditions for tests they currently perform, limiting access to treatment for Californians.

For example, a person who goes to a pharmacy and tests positive for strep throat would not be able to receive treatment by a pharmacist. They would have to go to a doctor or a healthcare facility. Recognizing the essential role of pharmacists, the Department of Consumer Affairs during the coronavirus gave pharmacists the authority to prescribe a COVID-19 treatment, PAXLOVID, directly to patients. This waiver is set to expire soon, meaning that they won't be able to do this anymore.

Building on this groundwork, SB 524 would allow pharmacists to prescribe treatment for four common conditions. While STIs were included in an earlier version of the bill, it's been removed and we're focusing on tests that are very simple to treat. They are COVID-19, influenza or the flu, strep throat, and conjunctivitis or pink eye. And if you've ever had pink eye, you know when you have pink eye again, but you can't get treatment for it unless you go in to see a doctor.

These conditions were selected because they are common diseases that plague communities and healthcare facilities, and they're easily treatable. I want to make it very clear that the Bill authorizes, but does not mandate that pharmacists participate in the test and treat program. There may be some circumstances where staffing does not warrant it so we've left it optional.

And the other thing is that what we've done is we've included an opportunity for the State Board of Pharmacy and the California Medical Board to create procedures and protocols to be able to give direction to pharmacists on how they should treat these diseases. And with that, I would respectfully ask for your Aye vote. With me here today is Lindsey Viscarra with the International Foundation for Autoimmune and Autoinflammatory Arthritis, and Mark Johnston with CVS.

Thank you very much. The first person, please.

Good afternoon, Madam Chair and Members. Thank you. My name is Lindsey Viscarra. I'm the Public Policy Manager for the International Foundation for Autoimmune and Autoinflammatory Arthritis, or AiArthritis, because that's a mouthful. I'm also a person living with psoriatic arthritis, and I'm the caregiver of two children with autoimmune diseases. I say that because our foundation is entirely patient-led. All of our staff are patients. Like many patients with chronic autoimmune diseases, we are all on immunosuppressive medications.

So anytime anyone in my house gets a sore throat, I panic immediately. And I know that a lot of our patients do as well. So every time someone gets sick, I weigh the consequences of urgent care against the consequences of waiting and seeing what happens. And either way, the consequences are terrible. If I could run to the Safeway a mile from my house instead of urgent care, because it always happens on the weekends that someone gets sick.

It would cut down on the time that my kids have to sit in a waiting room where people are coughing their heads off. It would cut down on the time that we wait. And I can buy Tylenol while I'm there, so everybody wins. In addition to the convenience, efficiency, and safety of going to the pharmacy for treatment, many Californians live more than 15 miles from the nearest healthcare facility. I live up in Chico, which is sort of semi-rural. We're down to one urgent care.

That's all we have left. There's a shortage of pediatricians. I can't always get into the pediatrician. There's a shortage of primary care physicians. Our choices are pretty limited. At the other hand, 90% of Californians live within 5 miles of a pharmacy. 8 million Californians live in areas of the state with healthcare shortages like ours, and many healthcare providers don't take all forms of insurance and many don't take MediCal. So it leaves all of those MediCal patients out of luck as well.

We should allow all healthcare providers to pitch in and help stop the spread of illness in communities like mine. I urge you to vote Aye on SB 524, which will help ensure Californians have effective, safe, and convenient treatment for common conditions like COVID, the flu, and strep. Thank you for your time.

Thank you very much. Next person, please.

Madam Chair, my name is Mark Johnston and I have been a California licensed pharmacist for over 30 years, starting my career at a community pharmacy in Truckee. I have served for pharmacy associations and a board of pharmacy where I developed my passion for protecting public safety and I believe that access to care is a cornerstone for which public safety laws should be built. That is why I am a strong supporter of SB 524.

8 million Californians live in areas with healthcare, professional shortages and a lack of available primary care providers. This is particularly true in rural areas. 61% of patients nationally report that it can be difficult to obtain care due to hours and availability. 48% say they don't seek treatment if it is inconvenient, allowing their symptoms to worsen and spread to others. It takes an average of 26 days to visit a primary care physician for whom many MediCal patients haven't even established.

Yet, 90% of us live within 5 miles of a community pharmacy with expanded hours and 60% of us already visit a pharmacy monthly. Where you have authorized pharmacists to furnish numerous prescription medications without a physician's order for years, including hormonal birth control, HIV prophylaxis, and more. Most recently, California pharmacists have successfully been furnishing prescription treatment for COVID.

SB 524 would continue this federal allowance and continue California's commitment to providing safe and effective access to testing and treatment by pharmacists by adding modest categories that other states have already enacted, such as flu and strep. Pharmacists have the education and accessibility to perform these tests, while physician-driven protocols already guide pharmacists through a myriad of inclusion and exclusion criteria that has resulted in a 22% referral rate to physicians for COVID treatment.

SB 524 will create standardized procedures and protocols designed and approved by the medical board. At CVS, pharmacist encounters are documented in the patient's electronic medical record via the most popular interfacing software, Epic, notifying the patient's primary care physician. Still, it is voluntary, not mandatory, for pharmacists to participate in activities allowed by SB 524. In conclusion, SB 524 increases public safety by increasing the channels through which infected patients can seek timely and accessible health care, especially for those who need it most, such as MediCal patients.

And I urge an Aye vote.

Thank you very much. Anybody else wanting to speak in support of this now? Just name an affiliation, please.

Thank you, Madam Chair and Members. David Gonzalez on behalf of the California Life Sciences, in support.

Thank you.

Good afternoon, Madam Chair and Members. Missy Johnson on behalf of the California Pharmacists Association, in support.

Thank you.

Good afternoon. Lindsay Gullahorn on behalf of the California Community Pharmacy Coalition, in support.

Thank you.

Good afternoon. Jaleh Donaldson on behalf of Cepheid, in support.

Thank you.

Maria Lopez, community pharmacist, in support. Thank you.

Thank you very much. All right now for the opposition want to come forward and oppose this Bill.

Good afternoon, Madam Chair, Members of the Committee, Senator Caballero. Want to just first. Alberto Torrico, on behalf of the United Food and Commercial Workers Western States Council. I want to thank the author and her staff for their work with us on amendments so far to narrow the Bill. I think we're still working on an amendment to further clarify the issue of privacy for the pharmacists. Let me address our last concern with the Bill as in print today.

We sympathize very much and acknowledge the issue of access to healthcare, particularly in rural areas, which Senator Caballero and others on the Committee represent. However, our concern is that while we shift some of these duties that are enumerated in the Bill to pharmacists, we might be creating another problem. Our concerns lies squarely in the fact that pharmacies currently do not have adequate staffing to complete their workload and pharmacists do not have autonomy over workflow decisions.

Pharmacists in the retail setting have been sounding alarm bells for years about their current working conditions. The California State Board of Pharmacy conducted a survey and the results were very alarming. 91% of chain pharmacists said that staffing in their primary work site is not appropriate or adequate to ensure adequate patient care. 35% of pharmacists in the chain setting indicated that they have, on average, three to five medication errors in a month, and another 45% said they have one to two medication errors a month.

That's 80% of chain pharmacists sharing that at least one medication error is happening a month. 83% of pharmacists said they do not have time to provide appropriate patient consultations, and pharmacists are saying that they don't have time to perform the proper review, even of immunizations currently in their scope of practice. I guess I think about all of our visits to our primary physician or even urgent care.

When you check into the facility, you see one person, they check you in, they check your insurance, they hand you off to someone else, not the physician. They take your vitals, then you go to the physician, you finish that, the physician gives you a prescription. That prescription goes back to the front desk. The front desk sends to the pharmacy. All of these duties that I enumerated are happening right now in the pharmacies by one person.

You know, when you go into pharmacy, the pharmacist is there, they take your prescription, they fill your prescription, they counsel you on the use, and then they ring you up. What we're saying under the Bill is if we want this implementation to be successful, the amendment that we're asking for is that there'd be an extra pharmacist assigned to each pharmacy that solely be assigned the duties in the Bill. Then we'll have a workable solution and we'll make sure that one the pharmacists are work.

And more importantly, we're going to make sure that the patients aren't prescribed erroneous medication that can often, too often lead to deadly results. So, respectfully, we ask for we have an opposed, unless amended position. Thank you.

Thank you. Somebody else wanted to speak in opposition.

Good afternoon, Chair and Members. George Soares with the California Medical Association. So we do appreciate working with the author thus far and the conversation with the Committee as well. CMA's concerns are focused on treatments that pharmacists would be allowed to prescribe to individuals at retail pharmacies under this Bill. The treatments are too expansive and a one-size-fits-all approach to treating illnesses can be dangerous for our communities.

We are aware that this Bill has been amended recently to include tests to treat for COVID, flu, strep throat, and pink eye. However, treatment plans for those illnesses are not always the same. The Bill does not consider individuals who have preexisting conditions. An individual's primary care physician should not be removed from that treatment process. Additionally, it is unclear how complicated medical cases would be handled and referred to appropriate medical providers under this Bill.

The Bill also allows pharmacists to prescribe antibiotics for a couple of the illnesses in here, which could have far reaching unintended consequences to the healthcare delivery system. We should not support policy that would further exacerbate any type of antibiotic resistance. We understand and appreciate the author's intent around access to care, but this measure does not achieve access. And furthermore, we don't believe that this approach achieves health equity in our most underserved areas.

Our underserved communities deserve to have access to a primary care physician and should not have to rely on getting their health care at Walgreens or CVS, which, respectfully, are not community pharmacies. We look forward to continuing to be part of the solution on access to care, but this measure does not strike that balance. CMA respectfully urges you to vote No on SB 524 today and at the appropriate time, happy to answer any questions. Thank you.

Thank you very much. Anybody else speaking in opposition today?Just now name and affiliation, please.

Ryan Spencer, on behalf of the American College of OBGYNs, we do appreciate the amendments regarding STIs, but remain opposed.

Thank you.

Madam Chair and Members, Tim Madden, representing the California chapter of the American College of Cardiology, in opposition.

Thank you very much. Now would be the time. We'd go to the phone lines. Anybody in support and or opposition? Just name and affiliation and position. Moderator, are you there?

I am. Ladies and gentlemen, once again, if you wish to make a comment in support or opposition, please press 1 then 0. We currently have no one queuing up, Madam Chair.

Thank you very much. Now's the time to bring it back to the Committee. Senator Caballero, you had one opposition say they weren't qualified and another one said there wasn't enough. Do you want to address that at all?

Well, I think that the challenge is there are going to be some on the qualifications. Let me just say that pharmacists are highly trained individuals. They go through very similar training as medical doctors. They just don't do the clinical. And so part of what we put in the Bill as a consequence is a training program that they would have to complete in order to be able to be up to date and ready to roll on what the current treatments might be.

And what are the issues and questions you might want to ask in regards to that kind of treatment? The issue of workload is a real issue and so, in that regard, we're having conversations about what does that look like. In particular in the small community pharmacies. The pharmacists do a whole bunch of things. It's their facility, right? It's their store, if you will.

And we want to be able to make sure that there is a private place that they can do the testing and then can also do the treatment and do the consult so that it's not out in the middle of an aisle somewhere. And so we're working on those kinds of assurances. But in regards to the whole issue of staffing, I hesitate to mandate what the staffing has to be.

There may be times, I know, when I've gone in for my vaccines at the pharmacy, you have to make an appointment, and you make an appointment when they're least busy, right where there's someone that's available that can handle the procedure. And so my guess is, I mean we can make that part of the Bill, but in terms of mandating the whole issue of the errors, that's something that the pharmacy board has to deal with. That is quality control, and I'm sensitive to it.

We really want to make sure that the prescriptions are going out appropriately, but I don't think it should impact whether or not. And I just got to say it, having done that COVID test every single week for almost three years now, I can do it in my sleep. And if you give me the pink eye test, I probably can do the. They're CLIA-certified, which means the FDA has come in and certified them. And it's a light that either it's positive or it's negative.

And so I just think that these are fairly simple tests. To me, the whole idea that it's going to be too difficult to be able to do that just doesn't make any sense to me.

Thank you. And I truly appreciate your dedication to rural California and try to expand access. It is a conundrum, and I appreciate what you're trying to do.

Thank you. And the other thing is that there's an argument that we're providing less qualified treatment to disadvantaged folks and that they should have doctors. It's like, hallelujah. That's exactly what I'd like. If we could open about 10 more medical schools and open them in rural California, and then provide incentives for doctors to stay in rural California, then maybe we can wait 10 years to be able to say, now we've provided equity, but in the meantime, we're not having equity.

And to say nothing is better than the status quo is better than trying to let pharmacists, or having them do this as well, go through the training, learn everything you need to do in order to be able to do this just doesn't make any sense to me. It's like nothing is better than.

I agree. It's like you have this or the alternative is nothing.

Nothing. Right. It's correct.

Senator Menjivar.

Thank you, Madam Chair. And I appreciate that, too. I think this is a creative approach to address. You have hospitals closing in your district, and a lot of other Members are facing that imminent doom there. So how else can we provide access while we're dealing with that for a permanent solution? One of my questions was addressed already. My other question was regarding privacy. Pink eye. It's hard to hide that.

I mean, it's pretty visible, but it's just like a strep throat or people who have the flu and coughing. How are conversations going there on how to address the privacy?

Well, the privacy really has to do with the space in the pharmacy to be able to get people, if not a separate room, then at least a screen so that they can go behind.

And I think my experience with the COVID pandemic is that they were able to handle that very well because you had an appointment, and if you came in for the vaccines, you had to wait in an area that was designated, and then they'd take you behind the screen, and then you had to fill out the paperwork ahead of time. And so the idea is that you're screened from the public, and it's not something that people can hear or see.

In the pharmacies that I was in, they were pretty busy. People aren't really being nosy about who's here, and let me take a look. And we got rid of the STD, so that, I think, makes it even easier in order to meet the needs of the flu, strep throat and pink eye. And one more. I'm forgetting it.

Covid.

Covid. Yeah. Whoa. How did I forget? How easy we forget. The issue around privacy has been the issue with the space and the ability to put up barriers. Quite frankly, the pharmacies have a really good system of electronically keeping information that your doctor can access and that transmits the information to doctors.

Right. I saw one of the provisions, maybe, perhaps, I felt addressed some of it is that the pharmacist will notify the patient's primary care physician. Right?

Correct.

Okay, thank you.

Thank you very much, Senator Roth.

Thank you, Madam Chair. You know, it occurs to me, I think we license pharmacies in addition to pharmacists in the state. And going back to what Mr. Torrico said in his opposition, we all want healthcare to be delivered in a safe manner. And if there are staffing issues or any other issues that result in unsafe practices inside a licensed pharmacy, it seems to me that ought to be within the purview of the board of pharmacy.

If Mr. Torrico disagrees, I'm sure he'll step up and say so. And if the board of pharmacy needs additional tools in order to ensure that licensed pharmacies are engaging in the activities we authorize in a safe manner then the other Committee that some of us sit on can certainly take care of that. So I'll be supporting your measure today, Senator.

Thank you very much.

From the Chair of Business and Professions.

Absolutely.

Seeing no other questions. Would you like to close, Senator?

This is really an access issue, and I respectfully ask for your Aye vote today.

Thank you very much. Still don't have a quorum, but we're getting closer.

Very good.

So any Members out there can hear the sound of my voice. We need a quorum. You want to move on with SB 621?

Thank you, Madam Chair. I'm pleased to present SB 621, which will increase patient access to lower-cost biosimilar medications in order to reduce healthcare costs and provide safe and effective treatment options. I will be accepting the amendments that address concerns raised by the opposition. Appreciate the committee's assistance to make it more explicit that important patient protections, including the ability of a physician to request a step therapy exception, would be applied to biosimilars.

Californians, especially, as I've said, rural residents, are confronted by such challenges as hospital closures, limited treatment access, and high healthcare premiums. I've been long concerned with the healthcare accessibility, and SB 621 will target a crucial area lowering the price of prescription drugs to lower health plan premiums. Per capita spending on prescription drugs increased 700% between 1980 and 2018, which is over a 30-year period. Many patients pay tens of thousands of dollars annually in out-of-pocket costs for life-saving medications.

Many others are forced to pay high healthcare premiums. High prescription drug prices also impact the bottom line of financially strained hospitals, particularly with recent inflation. It was one of the factors that they cited as an increased cost that makes it very difficult to meet the needs. The high cost of prescription drugs is in part due to the lack of competition that branded drug companies receive from lower-priced but equally effective treatment options.

There is a group of drugs called biosimilars that are very similar to generics but are designed for complex biologic but for common biologic drugs. These drugs are rigorously approved by the FDA as having, quote, no clinically significant difference from the brand name drug in terms of safety, purity, and potency. This means that biosimilars are just as safe and effective as a brand-name drug while also being less expensive. The introduction of biosimilars frequently leads to increased access for patients, driven by the lower cost of biosimilars-

-and price reductions of other treatments. Since biosimilars were introduced into the US, they have saved over $13 billion, and they are expected to generate over 180 billion in savings over the next five years. Despite biosimilars' widespread adoption in Europe, barriers to their adoption remain in the United States. This is due to the power of the prescription drug companies, which have exploited the legal system to block the widespread adoption of biosimilars.

This has resulted in tens of thousands of dollars in out-of-pocket costs for many patients facing conditions such as AIDS and arthritis. Currently, health plans may access a list of several lower-cost drugs for an enrollee before trying the brand drug. However, most biosimilars are excluded from this list. This means that many biosimilars cannot be used to lower healthcare premiums for patients. This bill would allow health plans to have the tool to directly access a lower-cost biosimilar before the equivalent brand drug.

The bill also extends relevant patient protections to the usage of biosimilars, such as the ability of a provider to request that the original brand treatment be used. A prescriber in California will have to approve the use of the biosimilar prior to it being administered to a patient so as not to interfere with the physician treatment decisions. Ultimately, SB 621 will give patients greater access to treatment for these diseases by helping patients access lower-cost and equally effective alternatives.

It will work to lower the price of the prescription drugs and reduce healthcare premiums without delay to help our financially strained healthcare system and ensure patients with chronic conditions. Again, these are chronic conditions. You don't just take the medication, and you're cured. These are chronic conditions, and they'll be able to get the assistance they need. With me today to testify is Brett Michelin with the Association for Accessible Medicines and its biosimilars council.

Thank you very much. Brett, welcome.

Good afternoon, Madam Chair Members. Brett Michelin with the Association for Accessible Medicines. AAM represents the generic and biosimilar manufacturers, and the biosimilars council is a subsidiary which obviously focuses on biosimilars. I'd first like to thank the Senator for carrying this bill, and we were pleased to sponsor it and for the work of your staff and her staff on its behalf so far. I will try and save you a little time today, primarily answer questions if you have any.

It's a kind of complicated area of law with the differences in the drugs, so I'll just wait and see if there's questions on that, but I do want to make a couple of points. If I can. The intent of this bill is truly to increase access to biosimilars, which are lower-cost drugs. And we do that by removing artificial barriers to their coverage. It's appropriate what this bill is doing by adding biosimilars to provisions of law that already include generic and interchangeable biologics.

What this bill does not do, but there has been questions on it, does not create an additional step for patients to gain access to drugs that their prescribers prefer. Also, it does not force substitution. Biologics or biosimilars are not substitutable at the pharmacy counter. So, as the Senator mentioned, the provider actually has to write the prescription for the biosimilar. It's not going to be substituted without the provider's engagement. Biosimilars do save money, and I do want to give a couple of specific examples to that.

Relatively new biosimilars to come to market. Insulin, obviously a drug that has raised a lot of questions and a lot of concerns about its costs. The first biosimilar to come to market was offered at a 65% discount from Lantis, which was the original or originator drug. 65% discount. It was also offered at a 5% discount with a greater back-end rebate. And that's because of the way that the market for biosimilars is starting to develop.

Another example, Humira, one of the most expensive, highest-grossing drugs ever produced around the world. The first biosimilar just came to market earlier this year. It was introduced at a 55% rebate. We have examples of that throughout the lifespan of biosimilar drugs. Oncology is a perfect example. One of the earliest areas where biosimilars became available, cost increase for the treatment of oncology were about 18% a year, each year going up 18%. When biosimilars came to market, that increase was cut in half at 9%.

So, costs are still going up for the treatment of cancer, but by half of what it was prior to biosimilars coming to market. With that, I'm again happy to answer questions if you have it, but we do have more examples of this, too.

Thank you very much. Anybody else speaking in support of this bill today?

Madam Chair and Members Rand Martin here on behalf of the AIDS Healthcare Foundation, which is the largest nonprofit serving people with HIV and AIDS in the State of California. This is a very important Bill to us in terms of increasing access to treatment regimens for people with HIV and AIDS. Thank you.

Thank you. Next person. Just name and affiliation.

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

Thank you.

Lindsey Viscarra, International Foundation for Autoimmune and Autoinflammatory Arthritis, in support.

Thank you. Okay, anybody speaking in opposition to this Bill today? Please.

Thank you. Madam Chair and Members Tim Madden. And I'm speaking on behalf of the California Rheumatology Alliance and the Coalition of State Rheumatology Organizations. We are removing our opposition with the amendments that the Senator just accepted.

I just want to take a quick minute to thank the Senator and her staff and the sponsors and especially your consultant on working on these amendments to help clarify, to make sure that we're all in agreement with what the law is doing going forward. And with that, we're removing our opposition. Thank you.

Thank you very much. Anybody else wanting to speak in opposition to this? Now just come forward. Name and affiliation. Seeing none, we'll go to the phone lines. Moderator, are you there? Anybody in the queue?

I am. Ladies and gentlemen, once again, if you wish to make a comment in support or opposition, please press 1 then 0. If you go into line 106, please go ahead.

Hi, this is Duke Cooney on behalf of ACLU California Action, in support.

Thank you very much, Duke. Next caller, please.

There's currently no one else in the queue, Madam Chair.

Thank you very much. We'll bring it back to the Committee now for any questions, comments? I think it's a good Bill. And again, really an issue around access and trying to save people some money. Would you like to close?

Respectfully ask for your Aye vote.

Thank you very much. And again, when we do get a quorum, we'll make sure those votes start happening.

Sounds good.

You have one final Bill before us today. We'd like to talk through that a little bit.

We understand that the committee is fine, and we've talked with leaders. Everyone's fine with this moving through. We understand it's a shell of a bill at this point. And we've all been working with the administration to try to really get them focused on an MCO tax we all know we need. And so, in order to put a little bit of pressure on them, we'll just have yours going alongside so we can be ready to be nimble. Would you like to proceed?

Yes, and thank you for that, Madam Chair. That's exactly right. As you know, hospital failures are not an option in our communities. We just can't afford it. And at the end of last year, it came to my attention that Madera Hospital was in distress. And I found out also that hospital in San Benito County, Hazel Hawkins, was also in distress.

Circumstances pushed Madera Hospital to a point where once they sent out the letters indicating they may be closing in 60 days, people left, and the hospital was forced to close right after Christmas, before the New Year's. They have since filed for bankruptcy.

And the challenge is that it was a perfect storm between the coronavirus that cleared the hospital of all of the surgeries that were not urgent and filled it with people that were very, very sick, and a high proportion of seniors, which mean they were on MediCal or Medicare, which doesn't pay reimbursement rate sufficient to keep a hospital open.

If that's the only patient that you're seeing, including the high cost of supplies because of the coronavirus and the high cost of prescription medications, it was a perfect storm. All these hospitals basically utilized their reserves such that they were to keep themselves open. And we discovered at the beginning of the year that there were about nine or eight hospitals in the state that were teetering on the edge of closing in bankruptcy.

And so we put together a committee of senators that could sit down and start talking about what are some of the options that we need to employ to be able to try to shore up these hospitals? And it was not just those seven or eight hospitals. This was seven or eight hospitals this year and another seven or eight hospitals next year. So, a majority of the senators would experience a hospital closing within the next two years, which would be a tremendous drain on medical services.

You'd see doctors leave the state; nurses leave the state. They'd be looking for a place to land where they could have privileges. And so we started working on some ideas. There's a bunch in the planning stages, but the MCO tax, which expired at the beginning of this year, became one of the focal points because the Governor had it in his budget in January. But consistent with what we've done in the past, the MCO tax is utilized.

It's a tax on managed healthcare systems, which is the insurance we all pay and because of that tax, we pull down additional federal resources. So, it has to be crafted very carefully. And the way that it works, practically, in a really simplistic way, is it goes straight into the General Fund and it backfills General Fund payments for health care. So there was some extra, but not much.

And when we started talking about how this tax should be structured and meeting with all of the different organizations, with the unions, with the healthcare providers, the doctors, the hospitals, everybody felt very strongly that the money should come back into healthcare because what we did is we expanded the number of people that were covered by MediCal, but we did nothing to bolster the system, to change it, and to make sure that people had primary care options rather than using the emergency care at the hospital for their first line of primary care.

Way too expensive, inefficient, and it doesn't work. Madera Hospital had three clinics, but when they closed their hospital, they closed everything because they couldn't afford to keep any of it open. And so the impacts are not just the hospital patients, it's the clinic patients. And then what came to light is it included the nursing students that were going to the community colleges and needed a place to get their hours.

And so we have this while we're trying to expand the medical school at UC Merced and at Fresno State, which has been a great partnership with UC San Francisco, their medical school. While we're doing that, we're letting the medical system collapse underneath ourselves. And so, this is a work in progress. There's a group that is working on putting something on the ballot. The challenge with putting something on the ballot is you can't change it.

And the Federal Government has rules and regulations we have to follow in order to pull down extra funds. So we need to be nimble on this. So this is the placeholder, and there's a lot of other work. I'll come back some other time, and we'll talk about the other things we're working on. But this is critically important to really look at the kinds of things that we could do with this.

So, for example, setting up a different system for mental health, 51/50s, rather than them going to the hospital, they go to another healthcare facility, get triaged, and go somewhere else. Tuition reimbursement for areas that have a lack of people that go to areas that have a lack of health care options. If people go to work there, nurses and doctors. So there's a way that we can use this to really bolster and change our health care system, and I'm hoping we get there.

So with that, I would ask for your aye vote today, and I'm going to apologize to staff because they wrote up some really nice notes, and then I just didn't use them at all, which makes -

Our staff get used to me. They're always helpful. We love them.

They're wonderful and they help me organized. With me today is Kathryn Scott with the California Hospital Association and Phyllis Baltz, who's President of the Methodist Hospital of Sacramento.

Ms. Scott.

California Hospital Association I'm going to be brief because how do you follow that when you have an advocate as strong for our hospitals and the distress they're in? I'll just go over a few statewide numbers and then honestly defer to our witness, who represents one of the largest MediCal providers in the state. Few numbers for hospitals. From 2019, we've lost about $20 billion, excluding the money that came from the feds for COVID Relief. So that's our net loss.

Over the last three years, 200 of our roughly 400 hospitals are operating in the red. Currently, 2022 was one of our worst years in the last three years, resulting in about one in five of our hospitals at risk of closure. Not only are those numbers coming up, the numbers in the negative, but because of the 19% increase in pharma costs, the 18% increase in medical supply costs, and the 20% to 22% increase in labor costs, we don't see those numbers, those negatives, operating margins coming down.

So for us, the MCO tax represents an opportunity to sustain the field in the long term. In some of the conversations we've had with senators, they're not only worried about the short, but they're really worried about the long term, not only again for hospitals, but for primary care providers. Our ERs are overloaded right now because we do not have primary care providers and specialists. So this, again, represents a great opportunity to sustain the healthcare field and invest at a time when we need it.

But I do want to make sure there's time for an actual provider.

Thank you very much. Next person.

Good afternoon, chair and committee members. I'm Phyllis Baltz, CEO of Methodist Hospital of South Sacramento. I'm pleased to be here today representing my hospital and 31 other dignity health hospitals in California. This is an important bill for our health system. Our system provides the full array of health services, including primary care, specialty care, ambulatory services, and acute care services. We are a critical community provider in many communities throughout this state, serving urban, rural, and suburban areas.

As the largest private provider of medical services in the state, Dignity Health considers itself a longtime partner in providing access to MediCal beneficiaries. We provide nearly 10% of the program's services annually. We have provided more than 600,000 inpatient days and 1.2 million outpatient visits. For decades, Dignity Health has worked to strengthen the MediCal program for the patients that we serve each year.

After all supplemental payments, including the hospital quality issuance fee, Dignity Health loses more than half of $1.0 billion based on our costs of providing care to MediCal beneficiaries. Like other healthcare providers, those losses are not sustainable and will ultimately result in declining services for MediCal patients or limitations in programs and services that are critical to our patients. Our hospitals and clinics are the lifeline for many communities. We also partner with other hospitals throughout the state to ensure services are provided to MediCal recipients.

As costs have risen considerably, especially as a result of COVID, we must seek a solution that will improve and sustain medical services by supporting the providers for the care of these patients daily. The MCO funds being discussed in Senate Bill 870 need to stay in the system, supporting our patients and those that we care for. I respectfully ask for your support of SB 870.

Thank you very much. Anybody else wishing to speak in support of this bill? Seeing none, opposition, or a tweener? A tweener.

Thank you, Madam Chair and Members. Nick Louisos, on behalf of the California Association of Health Plans and thank you, Madam Chair, and to the author for being gracious and allowing me to make comment today on SB 870. We don't have a support or oppose position on the bill, but since our association members are the ones that are paying the tax, we thought we'd provide our view on where we're at at the current moment. So thank you very much.

So, as many of you know, in the past, CAHP and California's health plans have supported ever-changing iterations of the MCO tax because of the substantial federal matching funds and other issues, as we've done in years past. We're currently working with the state, and the task ahead of us is made that much harder by ever-evolving federal guidance and interpretation of that guidance on this issue. Our position on the tax in the past and ultimately moving forward continues to be based on some fundamental principles.

So, we believe that the MCO tax must directly benefit and enhance services in the MediCal program. In other words, the revenue should be used to supplement and not supplant funding in the MediCal program. The tax must be affordable for the employers and individuals that are purchasing coverage, and it must be predictable, stable, and as equitable as possible.

Health plans believe that the revenue should be invested in areas that are of direct benefit to beneficiaries in MediCal, including primary care, specialty care, data sharing capabilities, and graduate medical education assistance. Our member plans and their customers purchasing coverage in the commercial markets also need confidence that the tax will be stable and predictable. We believe that there must be federal approval of the tax and that there must be federal matching funds associated with it.

The state should have to go back to the Legislature if there are changes to the tax as a result of negotiations between the state and the Federal Government, and the state should be required to provide some sort of reconciliation of the revenue and how it's being spent in the MediCal program. So I'll stop there. And I just want to, again, thank the chair and the author for letting me speak on this bill, even though we don't have a clear-cut position on it.

But I think it's important for us to begin the discussion here today. So thank you for your time.

Thank you for creatively getting your words out there. Okay, anyone wishing to speak in opposition, come forward. Name and affiliation?

Matt Lege, on behalf of SEIU. We don't have a position similar to cap, but just want to really stress the need with the MCO and the need to invest in the workforce. Thank you.

Thank you very much. Anybody else want to give your input on MCO? Okay. Seeing none, I'll bring it back to the committee for any. Senator Roth.

Thank you, Madam Chair. You know, I'm - healthcare in rural areas is a very difficult issue, and particularly where we are in a state where if you have a hospital, as I recall, it needs to be a full-service hospital with full-service lines, very difficult to staff, very difficult to pay for. But we have the system that we have. So, I think I'm obviously fully supportive of this MCO tax measure and look forward to seeing what the Administration proposes further in the budget.

But I think we certainly need to analyze the impact of the Medical reimbursement rate increases and perhaps targeted rate increases in rural areas and to see what we actually need to have in terms of an increase to make healthcare and hospital operations sustainable in these rural areas, and perhaps in nonrural areas as well.

I think we need to know what we need to do in order to stabilize the healthcare delivery system in areas like Madera and other areas in the Central Valley and some in inland Southern California, and I'm sure some in Northern California as well. It's important to be able to. That we're able to deliver health care and fulfill the promise that we've made with the MediCal expansion, and that's going to require an investment of resources, and this MCO tax should provide that.

But I think we need to know what we need to have at the hospital level, certainly, in order to make those hospitals stable. So thank you for bringing this, and thank you, Madam Chair, for letting me make a couple of comments.

Of course. Thank you very much. And anybody who has sat down, I think, and talked about MCO have all said about the need for the increase in medical reimbursement to make it sustainable, that we can actually provide the care that we're promising to people seeing nobody else. Would you like to close?

Thank you very much. I appreciate. Do you need to go to the -

I think I need to go to the phone moderators. Is there anybody in the queue?

Ladies and gentlemen, once you wish to make a comment in support or opposition, please press one, then zero. There's currently no one queuing up Madam Chair.

Thank you very much. See, we knew it. Okay. Would you like to close?

Let me just say that I really appreciate the comments that were made both in favor and in between. We're all working really hard together, and I want to acknowledge that CAPH came and basically said we want to be a partner.

And I want to thank them for that because they are the ones that get taxed, and they've come to the table before, and it's what it's going to take if we're going to be able to figure this thing out. It'll be a two thirds vote whether it's done in the budget or it's done in a separate bill. It's got to provide the real relief that we need.

And there are a myriad of issues that I think can be tackled at the same time that will make the system work much better. And so it's my hope that we can get there. It's tough to be doing this. Probably should have been a two-year bill that we work on really hard to make sure everybody's at the table. We got to get it done now.

And so with this expedited process, I need everybody to kind of come together and get things done because I appreciate, Senator Roth, your comments. The bottom line is that there are a number in the urban areas as well that are at risk. As a matter of fact, one that's in Whittier, Montebello. It's in that region in Senator Archuleta's district. So it's hitting us all very hard. And with that, I respectfully ask for your aye vote today.

Thank you very much. Thank you for spending time with the committee today.

Yeah, we all enjoyed it. Okay. All right, Senator Becker is up next. He's not here. He's there there he is. There he is. Okay. Yeah, let's see him. All right. Senator Becker.

Thank you. I appreciate it. It was loads of fun.

Good afternoon, Madam Chair and Members. California's public district hospitals serve some of California's most diverse and underserved populations and are the most local form of public hospital. But despite being the sole or closest source of health care for many families and seniors, district hospitals are the only public hospitals that are not allowed to directly employ physicians. This hurts their ability to provide services to their largely underserved patients.

As district hospitals are generally either rural and struggle to recruit physicians, or in urban areas where high cost of living make it difficult to recruit and retain physicians. Direct employment provides a way to compete with larger in or with larger labor markets to offer physicians benefits that make working at a public hospital more attractive.

Allowing physicians to choose direct employment, and this would be choice in this case, is particularly attractive to doctors coming out of residency or relocating from other states with direct employment of physicians more common and who would prefer to receive a set salary, benefits, and hours while still having their clinical autonomy as physicians respected.

Absent this change, district hospitals must continue to rely solely on contracting with physician groups or individual doctors making it increasingly difficult to ensure they can provide essential care to those who need it most. And I'll just mention Senator Hurtado brought up an issue to our office and we're meeting with her. And just to be clear, again, this Bill is not meant to encourage corporate influence at all, in any way.

And we certainly agree that making sure this is centered around the needs of the patients rather than the financial interests of board members or other needs of the community is preeminent. With that, we have two witnesses, Diane Hansen from the Palomar Health, and then Dr. Carmen Agcaoili from Washington Hospital ICU Medical Center.

Thank you. First supporter, please.

Senator, thank you. Madam Chair and Committee Members, good afternoon, and I appreciate the opportunity to be here today. Today, Palomar is the largest healthcare district in the state, entrusted to care for more than half a million residents. Our roots are traced to humble beginnings in 1933, when two compassionate women left their jobs to establish a 13-bed hospital to serve the small farming community of Escondido. Palomar's existence is closely tied to community as most district hospitals are. District hospitals are the safety net.

We are providers for people who face social, financial and access barriers to care. Nearly 60% of patients in our behavioral health programs or those receiving OB services are on MediCal. We are also operating in one of the least affordable areas in the country where housing, gas, and utilities make our cost of living 44% higher than the national average. While district hospitals are typically located in either underserved or high-cost-of-living suburban areas, Palomar is positioned in both.

Despite serving as the safety net, district hospitals are the only public hospitals prohibited from directly employing physicians. As a result, we are at a severe disadvantage for recruitment and retention. Direct employment provides stability for relocating physicians since it takes time to build a patient base. Right now, their income is dependent on billings, which is too risky when relocating to underserved and high-cost-of-living areas. There is no way for us to affect the clinical judgment of our providers, nor would we want to.

As a district hospital, our only goal is to provide care to our community as demonstrated by our continued expansion of services to meet the needs of our district regardless of profitability of these services. SB 784 is about equity across public hospitals and is a modest approach to allow a small number of hospitals a tool that has proven to be effective. For these reasons, we respectfully ask for your Aye vote. Thank you.

Thank you very much. Next up, Doctor, welcome.

Good afternoon, Madam Chair, Members of the Committee, and to all audience. Thank you for the opportunity to speak today in support of SB 784. I'm Dr. Carmen Agcaowili. I'm the Medical Director of the Critical Care Unit at Washington Hospital Healthcare System, a public district hospital in Fremont, California. I'm a pulmonologist and intensivist by profession, and with my team, I specialize in caring for the most critically ill patients. At the district hospital where I practice, we follow the patient-first ethic.

We focus on what is best for the patient by providing high-quality clinical care. I've been at Washington for the last 33 years, 17 in private practice and 16 in the large medical group. Locally governed and publicly accountable, my district hospital is responsive to our community health needs. During the public health emergency, Washington Hospital worked with the City of Fremont to offer free COVID-19 testing and launch a mobile testing unit for senior living facilities.

To date, nurses have given almost 100,000 COVID-19 vaccinations to the residents of southern Alameda County. I'm here today to respectfully ask your support for Senator Becker's Bill, SB 784. This Bill will promote, as you have already heard, health equity and access for allowing district hospital to directly employ physician. As it stands today, district hospitals, as you have heard, are the only public hospital barred from employing physicians.

Unlike county hospitals, children's hospitals, and academic medical centers. SB 784 would provide an important tool to district hospital to recruit and retain highly sought-after specialty physicians to share coverage and also prevent physician burnout. When I talk with my physician colleagues. We all agree that what keeps us up at night is whether our district hospital will have enough specialty physicians to treat everyone who comes to the hospital. Clinical practice guidelines are set by self-governing, independent medical staff organization. That's really to protect the patients.

The structure of district hospital does not allow administrators to influence those guidelines. I just want to reassure you that the hospital administration would not have the ability to direct clinical care if physicians were directly employed by the hospital physician practice medicine based on evidence and guidelines set by their respective medical societies. SB 784 would simply give public district hospital like ours an option that other public hospitals currently enjoy, strengthening our ability to provide essential local clinical services and to increase healthcare access.

Thank you for your time today.

Thank you very much. Anyone else speaking in support? Now just name and affiliation, please.

Thank you. Madam Chair and Members, Sarah Bridge on behalf of the Association of California Healthcare Districts, here as proud sponsors of the Bill. Thank you.

Thank you very much.

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

Thank you very much. Next person, please.

Good afternoon Chair and Members of the Committee. Ronnie Verdugo here with the California Hospital Association, also in support. Thank you.

Thank you.

Good afternoon. John Coan from El Camino Health. Proud to be here in support. Thank you.

Thank you very much. Okay, seeing nobody else approaching the mic. Now, we'll go to opposition. Please come forward. Like the supporters, you have six minutes.

Thank you, Madam Chair, Members of the Committee. Brandon Marchy with the California Medical Association here in respectful opposition to the Bill. A tremendous amount of respect for the author, Senator Becker. Unfortunately, we do think that this Bill just doesn't solve the stated problem of getting physicians into the communities that need care. Instead, SB 784 would wipe away long-standing protections for patients, for patients and providers from ulterior motives such as profits, shifting culture and political pressures, and faith-based beliefs.

With current attacks across the nation to cut abortion and other reproductive care, gender-affirming services, and corporate involvement in healthcare, it is more important than ever to defend patients' ability to get the quality care they need and deserve. It is our understanding that the Senator introduced the Bill to allow El Camino Hospital District to employ physicians. However, the exemption is not just limited to El Camino. In fact, it applies to any hospital district, whether they have other means to employ physicians or not.

A hospital district's inability to come to a negotiated contract with physicians that reside in and provide care to those communities is not a reason to come to the Legislature to undermine long-standing law that provides patients with the peace of mind that when they enter their doctor's offices, that doctor has their best interest at heart, not their employer.

Recently and over the last several years, studies and data have shown that healthcare costs rise significantly when care delivery moves from independent providers contracted with hospitals and other entities to hospital-employed or employed delivery systems. At a time where the Legislature has worked tirelessly to address costs and rising premiums, we think, in addition to the concerns that I raised before, this Bill takes a step in the wrong direction.

Additionally, the safeguards in SB 784 are not strong enough to protect the patient-physician decision-making body and entity, as those undue influences are extremely difficult to prove. The corporate practice of medicine bar is enforced via a lawsuit. Oftentimes, providers are smaller entities and do not have the resources to withstand that type of or sustain that type of lawsuit against a hospital system or other corporate interest.

At a minimum, the Bill should require a report from the Department of Healthcare access and information to see how often the exemption is used.

The recruitment and retention rate of physicians at the hospital from outside of the community since there is a charge that there are not enough physicians within the community and to assess the impact on patient-physician decision-making. To really address the issue, and I know that the Members of this Committee, we just got done with an MCO tax discussion, but to really address the issue of physician recruitment and retention in rural and underserved communities, California must address public payer reimbursement rates.

The ability of a hospital and physician to be payer agnostic and not lose money on a MediCal visit is crucial to the viability of hospitals and medical groups alike. Finally, decisions about patient care, regardless of the service, should be insulated from profiteering or political motives. SB 784 would eliminate the current bulwark that ensures that care decisions are made in the best interests of patients and are not encumbered by ulterior motives. We respectfully request your No vote.

Thank you very much, Mr. Marshy. Anybody else speaking in opposition to this Bill has come forward, seeing none. Moderator, anybody in the queue on this Bill?

Ladies and gentlemen, once again, if you wish to make a comment in support or opposition, please press one, then zero.

There's currently no one queuing up at this time.

Madam Chair, thank you very much. Now would be the time we would bring it back to the Committee for any questions. Comments? Senator Limon, thank you.

And I know we've had a little bit of back and forth on this, and so I was just a little confused. One of your witnesses is a physician, and on the other hand, there are physicians opposing this. And I'm trying to understand under what circumstances and conditions this helps some doctors, and this is a concern to doctors. And I've read both the BMP analysis and this one, the healthcare analysis, to try to figure out an arguments.

The same group of people are making arguments in support of the Bill but also opposed to the Bill. And I'm trying to figure out which one it is and under what conditions the same group of people would feel differently. Like what are the conditions?

And I'm happy to if you or one of your sponsors or anybody, it's just one of the pieces that I have not been as certain about as I've tried to kind of grapple with this, and also recognizing that I have a district with critical access hospitals that have this exemption or this ability to do some of what you've asked in this Bill. So just try and figure out.

Well, I think a couple of things. I think there's several points that were raised, and I certainly agree with the last one about medical reimbursement rates and making sure that's, I think, something we're all working towards. I think the General concerns around the corporate bar. Right. And the corporate practice of medicine. And I understand those concerns. And that's why this Bill is not a broader Bill about removing the corporate bar, although many states have taken that step. But we're certainly not advocating for that.

I'm not advocating for that. So I think that's where at least some of the concerns come in around from doctors about the corporate practice of medicine and whether there's going to be undue influence from the owners of the hospital, say, for example, whereas the public district hospitals themselves, if you heard they say, hey, we're the only public hospitals who don't have this, the other public hospitals have this, and we have protections in place.

And our Bill continues to mirror those protections, ensures that clinical judgment rusts solely with the physicians and not with Senator Tato. I also brought with an issue around this, around this notion of vertical integration. Right. We're very determined to make sure that we preserve the clinical judgment of the physician and that that's not eroded in any sense so I don't know. I can't speak.

I don't know if it fully answers your question, but I think the differences between the sort of a General concern about the corporate bar versus people who are in these very specific or running these specific district hospitals that see this need and enable for them as public district hospitals to be able to compete and retain physicians.

Senator, would you like to speak with the physician who testified? Sure. Be helpful. Yeah. Doctor, of course. The question is CMA, the organization is opposed. You are a physician and you're in support. How do those two things line up? Okay, as I said, my practice is in critical care, and I have a hard time getting specialized care in the hospital.

So I think it's probably not for all physicians, but for some physicians who just graduated from fellowship and things like that, trying to get a place to practice, this is something that we can offer. We can offer the specialty thing like trauma surgeons and specialty is something GI doctors, we're having a tough time getting them already in our community.

So if you're going to take care of the patient, whatever means to take care of the patient is what I'm open to, because really, in my experience with my district hospital is that it's two different bodies. This is the medical staff, and this is the administration. They're equally important. And they don't dictate right now. They don't dictate what we need to do. So, we are dictated by our clinical guidelines, by our medical specialty, and the one that peer reviewed us are the doctors.

So did I answer your question? Why is it that some doctors do not like it? And why is it that some doctors, just like in your other professions, too, some will take employee kind of a position and some will not? Like Kaiser Permanente. Right.

So I guess that I was trying to figure out under what conditions. So is the condition that if you are impacted and you are at a public hospital, then all of the doctors there think that this is the right approach, and if you are not, then they think that it's not. I just trying to figure out the conditions under which someone, the same group, the same body, would both agree and disagree.

Yeah. I think overall, even physicians and hospitals, their main objective is patient care. What is best for the patient, what's the quality for the patient. Right. But to get physicians, to get Administration are all two different kinds of things in our district. I can speak for my district where we're having a tough time getting specialists and the critical care intensivists, something like that. And some GI doctors so the differences is, number one, the need of a certain hospital and also the need of a certain physician.

Did I answer it?

One thing I think you just said was that some doctors prefer it.

Right? Yeah.

And it's a choice, but some, especially coming right out of residency, other things might prefer this if it was available.

Yeah, that's one of them. Some of them prefer it and some of them would not want it. And so maybe what they're saying for CMA, their stand is a little bit different from where we stand.

And is it appropriate chair to also ask the opposition to either? Certainly, yeah.

Thank you, Doctor.

And then I just want to wrap.

They're worried about the corporate world influencing it. Like Kaiser permanent is a corporate influencing the medical judgment of the physician. And so far, the district hospital where I'm in, as I said, these are two different bodies, independent bodies that work together for the patient care.

Thank you, Mr. Barge.

Thank you, Senator Limon. Following the good Doctor, of course, there are, of course, differences of how physicians like to practice in the State of California, right. Entities, larger entities, larger medical groups and health systems can provide economies of scale to increase efficiencies and billing and so on and so forth. However, when it comes down to and what we heard from the supporters, right. Is that there is a medical staff in each hospital and there is a board of directors of each hospital.

There is a concern that other Members within our organization and a majority of our Members within the organization have, in which that hospital board of directors has the ultimate and final say over what happens in that hospital.

If you recall, several years ago, our good friend, now, Congresswoman Cindy Kamlonger Dove, had a Bill on this exact issue, and there was a concern, and current law is sort of a little vague on the subject, that there is the ability of the hospital to make care decisions, and our physicians in those areas, regardless of public entity or private, are concerned that that entity is too far removed and has different motives as it relates to delivery of care and their ability to influence that delivery of care in that system.

Thank you. This is helpful. I think it was part of my own just kind of confusion of trying to understand and going through the analysis and trying to make sure I understood. I'm supporting your Bill today, and I look forward to better understanding. And I would probably echo the sentiment that if there is the ability, either now or in the future, to get more information on what the practice is, again, recognizing that I have a district where this practice has been in effect.

So whether that's through report or I think would be generally helpful to understand if this raises other bigger questions or not. So I would be supportive of that. I have to step out, and I don't know if you want to call quorum.

I would like to do that, yes, very much.

I'd like to clarify, Madam Chair.

Yes, but can we get a quorum first? Before, I wasn't leaving in General, and I will say that I've had talks with CMA, and they fully intend to come back next year. This has been kind of a dormant issue, and now we have a lot of new Members, a lot of new questions. And so I think they're really going to spend some time going forward and really providing some more education for all of us on the importance and or the relevance of maintaining the corporate bar.

Secretary, could you please call the role Senators? Eggman. Here. Eggman. Here. Min. Glazer. Gonzalez. Gonzalez. Here. Grove. Here. Grove. Here. Hurtado. Hurtado. Here. Limon. Here. Menjivar. Menjivar. Here. Roth. Here. Roth. Here. Rubio. Wahab. Wiener. Seven, and that makes seven. We have a quorum, Senator Roth.

Thank you, Madam Chair. I was actually going to make this sort of comment for Senator Lamone's purposes, but hospitals, these districts can be located in a variety of sections of the state and those that are located in rural areas where it's tough to provide health care and you're good if you can maintain a hospital to provide full-service care.

Hospitals try to recruit doctors, and when the doctor comes, the Doctor wants to set up a practice because most of them aren't hospital-based physicians, and they have to have patients, and they have to have a hospital to admit patients too often. And so, when a doctor is looking to whether to move to an area to set up a practice, they look at the availability of patients, the patient mix, the contracts, how's care going to be paid for? Can the Doctor make a living?

And in some of these rural areas, perhaps where district hospitals exist, and I'm looking, CMA can correct me if I'm wrong, it's difficult to make a living.

And in those circumstances, a physician who's willing to accept employment at a district hospital as an employee may choose and elect to go to that district to provide that area, that rural area to provide care, when otherwise they might not be able to do so, because given the number of physicians, the patient mix, how they get paid, or whether they get paid at all, they simply can't do so, cannot do so. And so that hasn't been mentioned.

I think that perhaps would have addressed Senator Lamont's concerns and as to the profit motive affecting medical decisions, we seem to have this employment model in county hospitals and some other similar hospitals in the state. And those hospitals have CEOs. The counties have CEOs. And as I used to tell the board of a nonprofit hospital that I sat on, nonprofit is a tax status. Every hospital has to make money, Madeira and others, in order to keep the doors open.

So those are just my comments, Madam Chair.

If it helps anyone.

Thank you.

Thank you very much. And I just had, in my district, one of my hospitals, it's going to stop their OBGYN delivery system because they don't have a gyn. So that means patients are going to have to drive from Tracy Mantika area to Modesta or Turlock, which can be a long time if you're in labor. Senator Grove. Thank you, Madam Chair. It's not very often that the Senator and I have something in common.

I do really believe that this Bill does help rural communities and rural hospitals and rural providers. I understand CMA's concerns. I really do. In response to Senator Ramon's questions and the comments that Senator Roth made, I think it's also the position in which these medical providers or physicians are in their process. I think the younger generation just coming out, know med school or have. I think they might embrace the fact that they will have an employer and not have to deal with all the stuff.

I don't want to say older, but the longer termed medical providers, physicians, I think they're like, this is my practice. These are my people. I'm doing my own thing, and you're paying me to be a contractor or whatever at the hospital, however it's phrased. So I do think that there's that avenue, that issue as well. Like I said, the younger ones might just want to come out and work directly for a hospital. I appreciate that you're giving us the option. I know that.

I do understand CMA's concerns. I know it came up last year. But I really do think that I got to vote for my district, and I think this helps the rural area. Community hospitals, like my colleague from Stockton, we're dealing with severe, distressed, financially distressed hospital situations and her hospital stopping labor and delivery. We lost a complete 170 bed unit hospital in the Madeira County, and within 30 days, we're going to lose a 650 bed facility in Tulare county with Kuya if something isn't done.

So that will have a severe impact on Fresno, kings and other areas. And that's all public. So I'm not throwing anything out there that's not public. And then we also had one in Senator Archuleta's district that filed bankruptcy just a few days ago. So we do have a problem. And providers can't practice where there's, I mean, they can't practice in their backyard. So we have to have a facility for them to practice in.

We have a lot of medical issues and provider issues and healthcare access issues that have to be addressed this year. And I appreciate you bringing this one forward. And I am going to go back to rules because the Senate pro tem is texting me, and she outranks all of you. Thank you, Senator Hurtado. You're recognized. Thank you, Madam Chair.

I want to express my support for the Bill today, but I do want to express concerns and want to hold my right to vote against the Bill down the road if necessary. But living in rural California, we face unique challenges and obviously struggles with critical infrastructure, including healthcare, including agriculture. And I feel like I've been seeing this trend of the need to come in and invest in rural communities, in sectors that are struggling, like agriculture, like rural hospitals.

And I'm very concerned about the issue of vertical integration in healthcare like I am in agriculture. And it's important to address the matter to ensure that we protect patients and improve the quality of care provided to patients. And I know that it's a difficult situation because we all don't want to lose our hospitals. We don't want to lose our doctors. We want to make sure that everybody gets the care that they need, but at the same time, we don't want history to repeat itself.

I mean, if you look at some of the scenarios that that occurred in 2019, I believe it was in New York with private equity firms going in, buying hospitals that are in disadvantaged communities and providing almost false hope. And almost immediately, they'd go in, filed for bankruptcy, and then would go back in and make a huge profit off of it. And then, of course, vertically integrate health care there and huge profits coming out. And so it puts all the patient at risk.

And so I think that you mean very well, and I want to support you, but I also want to make sure that we all have this in mind, that there's just schemes that are out there. And actually, the private equity firm that did all of this was based out of California. So I want us to be cautious in making sure that we don't allow this to happen here. So with that, I will be supporting your Bill today, and I'd happen to move it at appropriate time.

Thank you. Seeing nobody else wishing to speak sounds like you've started a very good conversation. Senator, would you like to close?

Thank you. I do appreciate it. I appreciate the remarks. I mean, just like schools are ultimately all about the teachers and attracting teachers, hospitals are all about doctors. And we want to make sure that whatever we do, we're setting up the conditions that the next kid graduating thinking about medical school does go there and isn't deterred by the dynamics of the industry. We want to make sure that they're attracted to the practice here in California.

I think this will help for this certain slice of hospitals, and I appreciate the comments. Asked for an I vote.

Thank you very much. Secretary, we have a motion from Senator Hurtado which is do pass and re refer to the Committee on Appropriations with a motion from Senator Hertato. Secretary, please call the roll. Senators. Eggman? Aye. Eggman, aye. Glazer? Gonzalez? Gonzalez, aye. Hurtado? Hurtado, aye. Grove? Limone? Menjivar? Menjivar, aye. Roth? Roth, aye. Rubio. Wahab? Wiener? Okay, that is five to zero, and we will take next. Senator Menjivar, it was okay.

Senator Menjivar, this is item number nine. SB 11. California State University mental health counseling.

Yes.

Please proceed when ready.

Thank you so much, Senator. Good afternoon, fellow Committee Members and interim chair again. First, want to thank the Committee staff for working on. For their support and working with my team on this analysis and this very important Bill. During the 2000 and 22,021 school year, more than 60% of college students met the criteria for at least one mental health problem, a staggering number that we continue to see increase, even more so in the pandemic.

Unfortunately, we're severely lacking in our mental health professional workforce, available to meet the needs of our CSU students. The International Association of Counseling Services, the IACS, which is how I'll be referring to it moving forward, recommends that colleagues and universities maintain a ratio of one full time equivalent mental health professional to every 1000 to 1500 students, which this Bill is looking to codify. SB 11 will also create a first of its kind, the CSU Mental Health Professionals act.

This act will incentivize CSU students to become mental health professionals in the state by creating a noncompetitive grant program to Fund training for licensure in California at a CSU or an underserved community. It is difficult to pursue a degree in a mental health profession, a social worker, when you're asked to do two years of unpaid work, something I had to experience myself. We overheard about the workforce shortages. It's been brought up here, and we know that universities are no stranger to the shortage as well.

Across the state, we're experiencing shortages in certain fields, as well as in those looking to address the student mental health crisis or the youth mental health crisis that we're seeing. The short staffing and mental health service providers at the CSU has led to wait times, where students are waiting around four to eight weeks to see a counselor. And just yesterday I met with several CSU students who told me that some of them are waiting close to three months for an appointment.

The demand for accessible student mental health resources has only increased in recent years as students struggle with economic, social and psychological impacts of the pandemic and entrance into adulthood. The CSU system educates close to half a million students each year and trains the majority of California's in such a workforce. With that in mind, we should be incentivizing CSU students to become mental health professionals and creating a strong student to workforce pipeline at the CSU.

So if we are calling for social workers and mental health professionals to be in all these different spaces, then we need to ramp up our workforce efforts. With that, I'd like to now turn it over, with the chair's permission, to my witnesses who would speak in support of this Bill.

First witness, please.

First one is Angel Marie Taylor, a student at CSU Channel Islands, and then followed by Jason Conwell, who is the staff on the CFA Counselors Committee.

Good afternoon and welcome six minutes between the two of you.

Good afternoon, Committee. My name is Angel Marie Taylor and I am a fourth-year business student at CSU Channel Islands. We are one of the very few CSUs that meets the ICS recommendation for students to counselor ratio. Having been a student here for four years, I very clearly remember what it was like when we did not meet the ratio. Wait times were anywhere between four to six weeks.

As a student who comes from a family of Low income and has to work multiple jobs year round to keep myself afloat while putting myself through college, mental health should be the last thing that I should have to worry about. In addition to that, I have experienced difficulty with housing insecurity and food insecurity along the way. These real trials throughout my pursuit towards education have been absolutely enormous and has taken a toll on my mental well being as well as my academic performance.

Now that we do read the ratio, instead of waiting one month, which was not quality and an effective form of mental health service for me, meaning the ratio, I can go and see a counselor today, tomorrow, anytime this week, and anytime next week. That works for me.

This difference has been monumental and I have never felt so supported, both in my personal life and academically, and my current grades stand to prove that, having been experienced both sides of the ratio, I strongly support SB 11 and find that this ratio needs to be mandated, not recommended, across all CSUs across the state. For other students who have experienced adversaries like me. Thank you.

Thank you very much. Next person, please.

Good afternoon. My name is Jason Conwell, and I'm speaking here on behalf of the California Faculty Association in support of SB 11 and to support the 270 mental health counselors we represent at the California State University. In one of my roles, I serve as CFA staff to the counselors Committee. In that role, I meet regularly with counselors from across the California State University, and I've done so for most of the past 16 years.

I have met hundreds of mental health counselors in the CSU, and I want to say these are some of the most impressive people I've ever met. They are empathetic, hardworking and dedicated professionals who help our student college students when those students are at the lowest points of their lives. These are honorable people who engage in critical and often life saving work, but they need help.

During my 16 years with CFA, I have watched as counselors have been pressured to hold more and more one on one sessions with students and exceeding any realistic expectations of the capacity of our counselors. I've watched as counseling centers across the state have eliminated permanent counselor positions and replaced them with counselors working on temporary appointments. I have washed as the mental health needs of the CSU students have increased exponentially both before and during the pandemic.

I have watched as more and more of our counselors have become tired and burned out trying to help every student that needs mental health support. Too frequently, I see our good counselors leave the CSU for a more reasonable workload, better pay and more job security elsewhere. While it won't solve everything, SB 11 will help address these problems. Over half the campuses in the CSU do not meet the 1500 to one ratio required in this Bill.

Seven of our campuses have a ratio that is at least 50% worse than the 1500 to one ratio. This Bill will help increase access to mental health counselors in the CSU for our students because our students just simply are not provided the access they need. SB 11 will also create new incentives and funding for students who want to develop a career in mental health, and that is simply needed. California needs greater access to mental health professionals.

Respectfully, I urge an I vote on SB 11, and thank you for your time.

Thank you very much. Anybody else wishing to speak in support now, just come forward. Just your name and affiliation. Good afternoon, chair Members. Priscilla, kudos here on behalf of California.

State Association of Psychiatrists, in strong support.

Thank you.

Tiffany Whiten with FAIU California co sponsors of the Bill in their strong support.

Thank you. Thank you.

Jonathan Karp, chair of the CFA retirement Committee and also the PLA, chair of the San Jose State chapter, in strong support.

Thank you.

Hello. My name is Rachel Flores. I'm a graduate student at San Jose State University in the Department of Chicana Chicano studies and strongly support this Bill. Thank you.

Hello. My name is Haley Powell. I'm a master of public policy student at Cal Poly SLO, and I strongly support SB 11.

Hello. My name is Lisa Kawamura. I'm a 25 year temporary employee at Cal Poly San Luis Obispo and the chapter of President for CFA at Cal Poly San Luis Obispo and I stand strongly in favor of this Bill. Thank you.

Hi. My name is Chris Natikia. I'm a 28 year faculty Member at Cal State San Bernardino, Vice President of the chapter and on behalf of CFA, speaking in support.

Thank you.

Hello, all. My name is Jennifer Chavez and I'm a second year sociology major at Cal State Long beach and I strongly support this Bill.

Thank you. Hello, all. My name is Luis Ortiz. I'm a second year communications student at Cal State Long beach and I strongly support this Bill.

Thank you.

Hello. My name is Khalila Mudari Spencer. I'm a fourth year at Cal State Fullerton and I strongly support this Bill.

Thank you. Good afternoon. My name is Garrett Desigan. I am a fourth year senior at CSU Maritime Academy in Vallejo, California and I strongly support this Bill. Thank you.

Good afternoon. I am excited to be here, but I'm a student at Calet. My name is Anabel Ranhel and I strongly support this Bill. Thank you.

Good afternoon, Madam Chair and old friend and colleague. I'm Kevin Weir, Professor of sociology at Sacramento State and Vice President of the California Faculty Association. Strongly in support of this Bill. Thank you.

My former colleagues. Yeah, my union Member, CFA. Good afternoon. I'm Dr. Nana Torres from Cal State. San Bernardino and I strongly support this Bill. Thank you.

Good afternoon. I'm Amy Escalante. I'm a lecturer at Csumb Monterey Bay and I strongly support this Bill. Thank you.

Hi, I'm Anne Johnson, a faculty Member at California State University San Bernardino and a Member of the CFA. And I strongly support this Bill.

Thank you very much. Now let's go to the people who are opposing this Bill come forward. At this time, we do have listed opposition, but I guess they're not going to come today. So anyone just wanting to say they're against it? Okay, seeing none. Moderator. Is there anybody in the queue?

Thank you, Madam Chair. For those who wish to speak in support or opposition, please press one, then zero at this time. Press one, then zero. We have several people who have signaled that they wish to speak. One moment, please. And we're going to first go to line 107. Your line is now open.

Thank you. This is Raj Fay. On behalf of indivisible California State strong. A coalition of 80 groups are in strong support of this Bill. Thank you.

Next caller, please, line 127.

Hi, good afternoon, California State University. We are not in less amended position on SB 11 legislative mandate.

Thank you very much. It's your name in position right now. Next caller, please.

Caller 138.

Hernandez. And I'm calling on behalf of the National Association of Social Workers and Support and as myself.

Thank you very much. Next caller, please.

Madam Chair, there is no one else who signaled that they wish to speak.

All right, thank you very much. At this time, we'd bring it back to the Committee for any questions. Comments? Senator Gonzalez?

I'll move the Bill when appropriate. I mean, obviously this has a price tag, but more importantly, this is so very important for so many of our students. Mean, I talked to many of my Cal State long beach constituents and I know the pain and the hurt. And you want more support from not just the Legislature, from your own CSU. And we hear you loud and clear. And I know with Senator Menjivar that we'll start opening a discussion and conversation on what this can look like.

And I look forward to working with you on that. So thank you for bringing this forward.

And Senator, the price tag of it. We are in discussions talking with budget, potentially looking at some HKI funding that could be put into this mental health workforce. So very mindful of that as well.

And you are accepting the amendments, right? Which we try to lessen the hurt of the technical. Technical amendment.

Yes.

On page four. Okay. Thank you. All right. Thank you very much. Okay, we do have a motion. Would you like to close? Was that your close?

I just want to say thank you. I think strategically brings some longitude students for the Senator, your ex colleague. I want to thank the witnesses who came and spoke about how difficult it is for them to seek mental health in schools. And I share in that. When I was a student as well, I went to seek for mental health during a very depressive time in my life.

And after explaining to them why I needed mental health after the quick 30 minutes intake, they said, we'll see you in two months. And they left me floored in that moment. And it could have easily deterred me. But I was able to go to the VA for it, but I had to go outside to find mental health where I was on the school campus. It would have been easier for me. So I respectfully ask for your.

aye vote on this, and I hope that we will continue to be working to ensure that it's a price tag that we can achieve and implemented. Thank you.

Thank you very much. All right, so that motion by Senator Gonzalez, and that is do pass as amended and re referred to the Committee on appropriations. Secretary, please call the roll.

Senators Eggman? Aye. Eggman? Aye. Min Glazer? Gonzalez. Aye. Gonzalez, aye. Hertado Limone? Aye. Menjivar? Aye. Menjivar? Aye. Grove Roth? Aye. Roth I Rubio wahob. Wahob I Wiener.

Six - zero. We'll leave that open for Members. Should we move on to your next Bill, SB 729?

Yes. Great. Hello again. Still me. I want to thank again, the Committee staff for working with my team on this very important and very personal Bill. SB 729 may sound similar to you because our other half was working on this last year. SB 729 is looking to require health plans to provide coverage for fertility care, including treatment for infertility and in-vitro fertilization, which I'll be mentioning as IVF.

Moving forward, I want to first ask the Committee to adopt the amendments as stated on page nine of the Committee analysis. I would like to move forward with this amendment. You should have the mock amendments in front of you that is going to limit this to the large group market by requiring health plans and insurers to offer this coverage.

So it's going to limit this to the large group market, and it's going to require health plans insurers to just simply offer this coverage in the individual and small group markets. The Pacific Fertility center of LA estimates that one in eight opposite sex couples will struggle with infertility, and that ratio doesn't even begin to include our LGBTQ plus couples. Data from the Pew Research center indicates that a full third of Americans have used fertility health services, or, you know, someone who has.

Yet right now, the safest and most reliable methods of fertility care remain out of the reach for most Californians. Current law right now mandates only that health insurers offer coverage for the treatment of infertility but does not require that all plans provide coverage.

Additionally, current law requires invasive standards of proof in order to access care, including needing an official medical diagnosis that could take years to achieve and to have completed one year or tried for one year unprotected sex that could have resulted in pregnancy, an act that simply most LGBTQ plus individuals cannot meet. Worse yet the law explicitly excludes any coverage of IVF, the most reliable treatment that has an up to 77% success rate.

For California struggling with infertility, the very existence of the family they hope to build can depend on income alone. SB 729 would expand access to fertility care for Californians, including coverage for IVF. Specifically, it revises current law to remove the IVF exclusion and to mandate coverage of fertility care for health plans regulated by the Department of Managed Healthcare and California Department of Insurance. As a reproductive freedom state, California still has significant work to do.

I will always be at the front line to ensure that people have a right to not have a child. But that also means that true reproductive freedom is that we're supporting those that decide if and when they want to have a child. For me and other LGBTQ plus same sex couples, access to fertility donors, doctors, potential donors, and options to intrauterine insemination and IVF are critically important.

About two years ago, I sat down with my wife and we decided, are we going to buy a house with the savings we have, or are we going to use that savings to start a family? For the past four months, I'm pretty sure you haven't heard me speak about a child. I have. So you could know what decision we had to make. And that was a tough decision to make, and that's the kind of decision I'm looking to remove from so many couples.

Committee Members, right now, 14 other states have already passed IVF insurance laws. In California always prides itself on being one of the first. Unfortunately, we're not the first, but we shouldn't fall so far behind. We must catch up to continue to earn our designation as a reproductive freedom chair. With that, with your permission, Madam Chair, I'd like to turn to my two witnesses here with me. First, I have Katie McKnight, who brings firsthand experience, followed by Dr. Ruben Alvaro, Professor of obstetrics and gynecology.

Welcome.

Good afternoon, Madam Chair and Members. My name is Katie McKnight, and I live in Richmond, California, with my husband, Nate. Two and a half years ago, I was diagnosed with stage two breast cancer at age 30. The type of breast cancer I was diagnosed with was fast growing and aggressive, known as triple negative invasive ductal carcinoma. At the time of my diagnosis, my husband and I were newly married with hopes for trying for a baby.

But we put our hopes on hold when I stepped back from work and underwent 16 months of cancer treatment. That entailed 26 rounds of chemotherapy, four surgeries, six visits to the emergency room, and hundreds of doctor appointments in between. I have known since age 24 that I have a pathogenic braca one mutation, a marker highly linked with the development of hereditary breast and ovarian cancers.

My father watched his mother die of breast cancer when he was young, and he watched his aunt and grandmother suffer through breast cancer and survive it. Since learning I was braca positive, I've done everything in my power to be as proactive with my health as possible. And despite my best efforts, breast cancer prevailed. SB 600, the Bill that established coverage for fertility preservation for patients like me, has had a profound impact on mine and my husband's life.

It allowed me to freeze embryos ahead of my life saving chemotherapy treatments. It allowed me to preserve hope that one day I may be able to become a mother with a biological child of my own, despite the copious amounts of toxins that my body has endured. Had it not been for SB 600, I would have had to try to come up with upwards of $20,000 in the matter of a few days to freeze my embryos ahead of potentially sterilizing chemotherapy.

SB 600 meant not having to choose between preserving my ability to become a mother one day and have to choose between very expensive cancer treatment. While SB 600 has made incredible progress in California to protect young cancer survivors like me, it does not solve the whole infertility problem. Now that active treatment is behind me, I am beginning to think about the next steps needed to build my family.

For me, this means the ability to implant my embryos and carry a baby to term, a service that is currently not covered by my health insurance. It also means screening my embryos for the brachy mutation to break the chain of malignancies that has plagued my family for generations. SB 729 is a critical step in helping cancer patients like me realize the promise that was critically stored ahead of cancer treatment.

Cancer survivors already face incredible challenges to realizing the dream of a family, the risk of cancer recurrence, the risk of permanent physical and emotional effects from cancer treatments, and the risk of just dying too young. But the risk of not being able to afford the substantial out of pocket cost of IVF for those who need it to have their children need not be included in this list.

On behalf of young cancer survivors like me and all Californians who are facing or May 1 day face infertility, I respectfully ask you to support SB 729 to bring more equitable and comprehensive infertility coverage to all Californians who need it. Thank you.

Thank you very much. Next person up.

Good afternoon. My name is Dr. Ruben Alvaro. I am a Professor and division Director of reproductive endocrinology and infertility at Stanford Medical School. I'm also the past President of the National Society for Reproductive Endocrinology and Infertility, which is the National Organization of Fertility Providers. I'm currently on the board of directors of the American Society for Reproductive Medicine and I'm also a 27 year veteran of the US army, where I took care of infertility patients in the military.

Infertility is a disease and it's not unlike diabetes and heart disease. It profoundly affects the quality of life for those affected, and its impact can be profound in the one in eight Californian persons who are affected, both the World Health Organization and the American Medical Association, along with every reproductive medical organization that I'm aware of, supports the diagnosis of infertility as a disease. Quality care unequivocally has been shown to be effective in treating conditions in most cases.

Unfortunately, there is unequal access to quality fertility care since even in the most affluent country in the world, only 14 states have some mandates for insurance coverage. Unfortunately, California is not one of those states. Prior to coming to California, I practiced in Rhode Island, which is one of those states, and I had the privilege of caring for fishermen, bus drivers, cops, teachers, firemen and just about every sector of the local community.

At Walter Reed, where I was the division Director as well, I cared for all ranks equally, from enlisted to noncommunication officers to company grade to field grade to even General officers. So, it was an equitable population that I cared for. Fertility care has been shown to be cost effective in multiple journals and in multiple mandated states. Estimates for the cost of a single birth generally range from 25,000 to 30,000, which is exceptionally good in the cost effectiveness world.

Additionally, mandates have been shown to allow for effective conservative management prior to the use of aggressive treatments and also to foster the use of safer approaches such as transferring only a single embryo, and this improves outcomes and reduces costs. As a native Spanish speaker, I am also used to serving the Hispanic community and usually about a third of my patients are Spanish speaking. Sadly, given the absence of mandated care in California, I speak very little Spanish in my clinics.

Doctor, if you could wrap it up.

Okay, thank you. So, fertility service are considered the standard of care in any community and are part of the continuum from pre pregnancy to neonatal care. Lack of a well resourced fertility care represents a gap in the spectrum and absence of this support puts California behind those states and medical systems that have chosen to do the right thing. I ask that you support Senate Bill 729.

Thank you. Thank you very much. Others wishing to speak in support, just name an affiliation.

Madam Chair and Members, I'm Erin Evans. On behalf of NARAL Pro Choice California, a proud co-sponsor of this important measure, as well as the California Nurse Midwives Association and support.

Thank you.

Thank you, Madam Chair and Members, David Gonzalez, on behalf of the California life sciences and support.

Thank you, Madam Chair and Members, Michelle Turan Wolfork with the California Commission on the Status Women and Girls in strong support.

Thank you, Craig.

Pulse for Equality California and strong support.

Thank you.

Mimi DeMiso, our family coalition, we're one of the co sponsors, in strong support.

Thank you.

Katie Fisher, on behalf of the California Department of Insurance, in strong support. Also in my personal capacity as the parent of two donor conceived children, in support.

Thank you.

Hi, I'm Joyce Reinecke with the alliance for Fertility Preservation. We are also a proud co sponsor of this Bill and in strong support. Obviously, and from my personal experience as a cancer survivor who also needed to go through IVF, I personally support the Bill. Thank you.

Hi, again. Katie McKnight, speaking on behalf of the board Member for the Bay Area Young Survivors, in support.

Thank you, Madam Chair and Members, Jose. Torres with health Access California, in strong support.

Thank you very much. Now, we'd go to those speaking in opposition today's.

Thank you, Madam Chair and Committee Members, Preston Young from the California Chamber of Commerce here today in opposition to SB 729. From the outset, I just want to make it abundantly clear, we are not here opposing this based on the policy that is attempting to be forwarded and achieved with SB 729. We understand that this is a well intentioned Bill. We understand what it's trying to do, and we can certainly empathize with that and sympathize with that.

The reason for our opposition are the unintended consequences that are associated with SB 729, primarily the costs that are associated with implementing this mandate. So the California Health Benefit Review program conducted an analysis of this Bill, and they did a few different scenarios. Now, one of the scenarios they analyzed was the scenario that the amendments will address, where this is only mandated upon large group health care benefits. Now, in that case, collectively, it will increase premiums for California's employers to three hundred thirty-two million dollars.

I realize when you break it down per Member per month, we get down to dollars and cents, and sometimes it almost invokes an eye roll where we think, okay, that's such a small amount. When we collectively look at this, what's the big deal? But this one in particular is going to increase per Member per month close to the $4 range, which is a large increase. And to put that in perspective, in context, this is just one piece of legislation that's going to do that.

That will then be layered on top of other healthcare cost drivers in the system. So that includes inflationary issues that are going on in the economy right now. That includes point of care costs increasing. That includes pharmaceutical care costs increasing. That includes labor costs increasing. Those are all health care cost drivers independent of legislation that is pushed through this body. So when you layer it on top of that now, it's one more expense that employers in this state have to pay.

And it's not just all employers now. It's only focused on the large employers in our state because this will only apply to large group benefits. To drill down a little bit further in regards to context, when we look at healthcare affordability in California over the last five years, the average premium for family coverage in employer sponsored plans has increased 20%. Now, what's that mean when it comes to dollars? So in 2022, the average annual premium for California employer sponsored family healthcare coverage reached $22,463.

So that has to be paid over a 12 month time period, and employees on average contribute $6,106 to those premiums. So one piece of legislation is going to increase that amount that is paid over a 12 month time period. Again, I can't reiterate this enough. The policy here is not the issue. We're just pointing out the concern we have when it comes to this acting as a healthcare cost driver, all mandates do, but this one in particular is a very large one.

So I really do thank you for your time and consideration on this. Thank you very much.

Thank you very much. Next person. Thank.

Thank you, Madam Chair, Members of the Committee, Jet Hampton with California Association of Health Plans. Regrettably here in opposition, I do want to thank the author and the witness's support for sharing their stories. We are obviously sensitive to and appreciative of the intent of this Bill. I would echo my colleague from the chamber's comments around that as well. Regrettably, our opposition is also based in the overall costs associated with the Bill.

As I mentioned on a previous Bill, we have 23 mandates that were introduced this year with a premium impact of $1.28 billion on Californians. This, unfortunately, is one of those bills, but again, certainly appreciate the intent. However, due to the cost impact, we are regrettably opposed. Thank you. Thank you very much. Okay, anybody else just name an affiliation at this point. Stephanie Watkins, on behalf of the Association of California Life and Health Insurance Companies, in opposition. Thank you.

John Winger, on behalf of America's Health Insurance plans and opposition.

Thank you very much. Seeing nobody else go, the phones, moderators or anybody in the queue, please, gentlemen, if you wish to make a comment in support or opposition, please press 10. We go into line 106. Please go ahead. They just removed themselves from the queue, so we'll be going to line 105. Please go ahead. My name is Jessica Tinkopa. I am a California resident and my husband Robert Tran and I have submitted a written position statement in strong court of SB 29.

Respectfully ask, please review and thank you very much. Next caller, please. And now we'll be going to line 106. Please go ahead. Good afternoon, Madam Chair and Members. My name is Duke Cooney. On behalf of ACLU, California action in strong support. Thank you. Thank you. Next caller, please. Next, we're going to line 133. Please go ahead. Anna Hornbossel and Mission Viejo in strong support. Thank you. Next caller. Next, we go under line 134. Please go ahead. King of Britt Carlson of Orange, California, in strong support.

Thank you. Next caller. There's currently no one else in queue. Madam Chair, thank you very much. This time we'll bring it back. The Committee, Senator Roth.

Thank you, Madam Chair. I'm wondering if one of the opposition speakers just could clarify for me the increase in employer cost. I want to first thank you for breaking it down per employee. A year or so ago, I was asking questions on that very issue, and I appreciate you all responding to my, if you responded to my questions, I appreciate it. If not, I still appreciate it, but I may have missed it. I thought there was $22,000, but I can't recall.

So the $22,000 that I cited. That's the average family employer sponsored health plan premium cost in 2022. And that was a study and a survey done by the Kaiser Foundation Family foundation.

And so then the employer portion of that cost would be.

Well, the employee portion. Employer on average for that study was $6,106. So the remainder would be on the employer.

14,000 or so.

Yeah, 16 area. Okay.

I appreciate it. Thank you.

Thank you, Madam Chair, just. If I could just make a comment. I mean, I think obviously, each of these bills, this one in particular, these are very important issues and benefits to be provided and services to be covered. I think there is value in the point made that as we keep layering benefits on top that need to be covered, those important coverage benefits need to be paid for somehow.

Okay.

And I think as I'm supporting this Bill and I've supported others and will continue to support bills to provide health care to those in need, I think we are all going to have to get together and figure out how this is paid for, because someone has to pay for it and nothing is free.

I think the chair in another hearing said that we're playing whack a mole, and eventually we're going to have no more moles left to whack in this, and I do agree with you, General, is that we need to come to the end game here of ensuring just, equitable access to insurance here. This is not a one and done type of Bill. This isn't the end all solution, but it is the step in the right direction to ensure that.

I agree.

And I recognize that when we're looking to remove discrimination in healthcare coverage, that there is going to be some prize to the whole pool, but it shouldn't be on the backs of those that have been discriminated against.

Thank you. Sounds like a very eloquent chair, Senator Grove. Thank you. Thank you, Madam Chair. Thank you, Madam Chair. This is a difficult Bill for me because in the real world, I wear two hats. I am an employer, and our cost for benefits that we provide our employees went up $16,000 a year last year, and like $14,000 a year before that. And I think it is a direct reflection of the policies passed out of this building.

On the other side of that, I have an employee that scrims and saves every single dollar she can save to do in vitro, and they've tried it twice and it hasn't worked. And it's a very expensive procedure. And I have somebody in the community, and they'll kill me if I use their real name. So, I can't do that. But I just recently saw her.

I was doing retail therapy in my Senate, colleagues from Stockton's district, and she happened to be there, and we ran into each other and she had a baby in her arms. And my first thought was, and it was kind of not a good thing to say, but I said, I thought you had cancer and got chemo treatments. She goes, I did. And I knew what she did for a living, and I knew she didn't have the insurance to cover in vitro.

And I said, did you adopt? And she goes, no, she's mine, and I have four more eggs. Because this person we both know found out when I serve him coffee every morning that I had cancer and said, but you just got married and you don't have a baby. And in his mind, he's thinking, that's the way things go.

And he went outside and wrote her a check to provide for these services so that once she got through with cancer treatment, she would be able to do this in vitro. Now, if it hadn't been for that very generous individual, she would not have that baby. And so, there's a lot of reasons, very good reasons to support it, and I understand that completely. But I also agree with the General. Somehow, some way, somebody's got to pay for all this.