Senate Standing Committee on Health

Participant number is 877-226-8163, and the access code is 736-2834; we have 15, well, now 14 bills on the agenda today. Three of those bills are on proposed consent and that is SB 10, SB 502, and SB 639. Three bills were pulled from today's committee hearing. That is SB 67, SB 551, and SB 774. Okay, having established all those, we're not running with a full committee, so we'll start as a subcommittee. So, we have our first author here. I see. Senator Portantino.

Good afternoon, Madam Chair and Members. I'm here to present SB 234. I'd like to begin by accepting the amendment B outlined on page six of the committee analysis and thank your committee staff and my staff for working so diligently on the bill. So happy to take amendment B. I'd also like to thank Senators Ngyuen, Roth, and Limon, who are on the committee, who are also co-authors of the bill.

SB 234 would require schools, college campuses, stadiums, concert venues, and amusement parks in the state to maintain unexpired doses of noxalon hydrochloride, also known as Narcan. We saw a spike, unfortunately, in adolescent death rates from opioid overdoses from 2019 to 2020, nearly doubling in the number, and have continued to see an alarming increase within the past year. It was also found that 20% of 42 Bay Area school districts reported not having Narcan readily available on their school campuses.

It's crucial that we place Narcan in spaces frequently accessed by Californians, given the severe risk posed by our state's growing opioid crisis. Narcan is a medication that has the potential to save lives from ending in death after an opioid exposure. We know that states that have implemented distribution programs have seen a significant reduction in death rates by following this approach. This bill will help equip schools and other venues with the resources they need to protect students and keep our communities at large, safe.

I wish we didn't have this crisis. I wish we didn't have an opioid crisis. It breaks my heart every time a constituent, family, or you see somebody on the news. I mean, it's heart-wrenching. And to know that we have something that can help in that emergency, we should try to make it readily available. I've been at places in my district where it's given out to homeless, which it should be. We try to put it out in circulation as much as possible.

And what this bill seeks to do is to make it available to those venues that we know our young people go. And so with me today, I have Adrienne Shilton from the California Alliance of Child and Family Services and Kim Stone from the California District Attorneys Association to testify in support. And I would respectfully ask for an aye vote when appropriate.

Thank you very much. First witness, please.

Thank you. Good afternoon, Chair and Members: Adrienne Shilton with the California Alliance of Child and Family Services. We represent 160 nonprofit, community-based organizations across the state serving children and youth, and families. So, we're proud to support SB 234 today. Our members serve students in a variety of settings across the state and recognize the need to have these life-saving medications, such as naloxone, available on school campuses.

We already have existing law in our state which authorizes each public and private elementary and secondary school to determine whether to make emergency naloxone and trained personnel available at their school site. However, due to the availability of opioids and their impact on youth across the state, we believe that we must take further precautions. The opioid crisis has been heightened, and we are seeing tragic deaths linked to opioid overdoses at alarming rates.

So, for example, the California Department of Public Health has reported a total of over 6000 deaths related to any overdose in the last year, and that's up from 5500 in 2020. So, we believe that we must have naloxone, more commonly known as Narcan, more readily available in schools and other venues to reduce these opioid-related deaths. So, we believe that SB 234 will better equip California to deal with our opioid crisis. And so we are pleased to support SB 234 today. Thank you.

Thank you very much. Next person, please.

Good morning, Kim Stone: Stone Advocacy on behalf of the California District Attorneys Association. So, I wasn't going to start my remarks with my allergies, but I have substantial seasonal allergies, and I now use Flonase year-round, which I highly recommend to any of the rest of you who have it. And every morning, it's not exactly a snort.

It's really kind of easy to plunge, push, and inhale at the same time, which is very similar to how one would administer naloxone. It's extremely simple, and I think you have all heard from many other witnesses in many other bills. The problem of opioids. In 2021, in California, we had 224 fentanyl-related overdose deaths in teens ages 15 to 19, per the California Department of Public Health.

And in the United States, for the CDC, our minors ages 12 to 18 overdose; this is all drugs, not just opioids. At a rate higher than the rest of the United States. And then for adults 18 and up, fentanyl kills more people each year than auto crashes, gunshots, suicide, and more even than died by COVID-19 in 2021. My clients, the district attorneys, don't believe that this is the only part of the solution.

They've got a bunch of other bills they support that are actually unlikely to proceed, but this is one that might actually be able to do something. And so we urge your support.

Thank you very much. Anybody else? Now would be the time. Just name an affiliation.

Madam Chair. Bob Jerome, on behalf of Pinnacle Aegis Treatment Centers, we have 44 medically assisted treatment centers throughout California, and we support the bill.

Thank you. Melissa Cortez with Governmental Advocates on behalf of the San Francisco 49ers. We apologize for not having our letter in. We are working on that and want to thank the author and his staff for working with us on technical amendments around stadiums and concert venues.

Thank you.

Thank you. Good afternoon. Samara Palko with the California Catholic Conference in support.

Thank you. Crystal Kudos on behalf of the City of Santa Monica in support.

Molly Sheahan with the Catholic Conference in support. Thank you.

Thank you.

Thank you. Leandra Clark Harvey with the California Council of Community Behavioral Health Agencies in strong support.

Thank you.

Corey Hashida with the Steinberg Institute in support.

Thank you very much. We have no listed opposition to this bill. If there's any opposition that you come forward now. All right, seeing none. Anyone just in the room? All right, seeing none. We'll go to the phones for people. Just name, affiliation, and if you're for the bill or against the bill. Moderator, please.

Well, ladies and gentlemen, if you have opposition or for the bill, press 1 and 0 on your telephone keypad. And. Looks like we have a comment from line number 49. Please go ahead.

Good afternoon, Chair and Members. Sam Nasher, on behalf of the Los Angeles County Superintendent of Schools, Dr. DeBuardo, in support. Thank you.

Thank you very much. Next caller, please.

Next caller is from 952. Please go ahead,

Madam Chair. Toni Trigueiro, on behalf of the California Teachers Association, in support. Thank you.

Thank you very much. Next caller, please.

Next caller is from line number 55. Please go ahead.

Good afternoon, Madam Chair. Larisa Cespedes here on behalf of Govern for California in support.

Thank you very much. Next caller, please.

We have no further opposition, or you may proceed.

Okay, thank you very much. Now would be the time to bring it back to the dais for any questions and or comments. Senator Menjivar?

Thank you, Madam Chair. You know, I appreciate the witness who shared that. She compared it to putting. Was it Flonase; how easy it was? I worked as an EMT, and my scope of practice, I would question like, but it's so easy. I can just give someone Tylenol. I can just give someone this.

But it wasn't within my scope of practice, even though it was really easy to do. An EpiPen is not within a scope of practice for an EMT to do in every single county just because it wasn't within the scope of practice. I do have some hesitancy to move forward with a bill that goes against the standing order that requires training for this. And I do know we have a bill later on that took the amendments for training.

I know it's important, but I put on my hat of I was an EMT. I know these laws, these orders are in place for a certain reason, to protect sometimes the unintended consequences out of that. So, I'm still very hesitant with this. Recognize the important but that training part is what I'm really worried about.

Thank you. Do you want to respond to that, Senator?

Yeah, I mean, the Food and Drug Administration is making it available over the counter, and it's going to be available online. Existing law allows the training to be permissive on campuses. I just don't want to overburden the school district with the mandate of the training when this particular product is so simple to implement. I respect the issue with EpiPens. I think that's a little bit different, a little bit more complicated than Narcan.

I mean, I've been at homeless shelter events where we just give it, and if we're giving it to one segment of the population and with the understanding that they're capable of administering it, I think on a school setting or in a concert venue, we should have it be the same. So I just think the mandating training for something this simple and this regularly available product just makes it overburdensome. It's a judgment call.

I respect the discussion piece because the question is, does it make it more efficient, or does it make it more burdensome? And that's what we're really talking about here. I'm siding on making it less burdensome and think that, on balance, will get to more people and help more people. And this training side, you can make that. So I think it's just where we see on the spectrum of that conversation.

So I really respect the question, but I just think, on balance, we're going to help more people if we make it more readily available. And that's where I'm erring on that side.

Okay. Anybody else? Senator?

Thank you, Madam Chair. I agree with the training aspect, and in some cases, I just wonder, in this particular situation, given the nature of this epidemic, if you can call this an epidemic if we shouldn't err on the side of putting more of this out everywhere.

And to have someone think that since they haven't been trained, they can't administer the Narcan naloxone, I think, creates a problem that we may want to try to avoid because the consequences of not doing it all, I think, at all, are certainly greater than the consequences of not fully administering the plunger or things like that. I'm certainly no expert.

I defer to people who are experts, including my colleague, who is a licensed clinical social worker and has experience as an EMT and probably in a variety of other healthcare arenas on the subject. But I just wanted to throw that out there as my two cent. I obviously will be supporting the measure. Thank you, Madam Chair.

Thank you very much. I will say that you and I have had conversations that I think the training is important. The last bill that we are kind of working off, AB 381, it has training as a component of that bill that would allow schools to be able to do this. Now, we're going to mandate it. And most people get the dosage from the Department of Healthcare Services. That's where they get it from.

And there's a free online training that does not seem to be overly burdensome at all. We live in a litigious, just. I worry about educators having to recognize the signs and symptoms of an overdose versus a seizure versus something else and then feeling comfortable enough to administer it and thereby potentially standing by and doing nothing. And then I also then worry about if we're going to have - if people are going to be again.

But also, as somebody who has worked in the healthcare field, the scope of practice is important, and a training - I went through it this morning, and it was pretty unburdensome to do the training myself this morning. And there was things in there that I didn't know, and I've shared with you, I won't be supporting this bill today. I think there is an epidemic. I'm not going to stand in the way of it. But the training does not seem to be burdensome.

And if we're requiring it and mandating it all these places, at some point, do we then run into a problem with supply? And we don't know that. And we don't know if it would not then have enough for folks who are out on the streets using. And I would argue that the folks in the homeless camps who are giving it out have been trained. That's their job, is to go out and contact folks who are in the camps.

And as you've already said, it's going to be over the counter now, and I would imagine those who are buying it over the counter are those who are users and or know people who are using. So that's their own personal choice. But we're telling schools that they have to do it, which then I think we just get into more gray areas. So I will hope that you'll maybe continue thinking about taking some amendments, and I can support this when it's on the floor.

Would you like to close, sir?

I would. And as I said, this is really a conversation about philosophically what we think will help the most people in a time of crisis. And I agree with the general that just having more of it in circulation, having more of it available, I think, is going to save more lives than a procedural issue. And I also think it potentially makes the bill harder to get a signature down the road, too. And so I just want to err -

- on the side of free training makes it harder to get a signature.

The mandate part on the training, making it only applicable to a school that has the training. It's not the training itself. It's the saying that you have to have the training in order to have the product. That's the piece. It's not the training. It's the burden that, that puts on that school district. And so I think that makes the Bill harder to pass. So with that, I respectfully ask for an aye vote and respectfully disagree with the chair's analysis.

Okay, well, thank you very much. And while we have a quorum, we'll take a vote. Thank you, Senator Durazo.

Ready? Thank you, Madam Chair, and Members, and to the Committee staff for their thoughtful analysis. I will accept the Committee amendment on page seven of the analysis. SB 424. The California Children's Services Modernization act will help make life saving medical care for critically ill children accessible and affordable for more families. Established in 1927, the California Children's Services program cares for children with complex and or life threatening conditions such as cancer but needs modernizing. This Bill will align the CCS California Children's services medical eligibility with best practices. Additionally, it will update financial eligibility so moderately middle class families with critically ill children can avoid financial catastrophe. Third, this Bill will make reimbursement for CCS providers more sustainable as rates have not been updated since 2002. Children's access to life saving drugs in hospitals is jeopardized since the Department of Healthcare Services doesn't cover these expensive drugs the same way as outpatient. So this Bill would equalize drug access. We also want to preserve the proven CCS expert case management and support by maintaining the separation from MediCal managed care. The children in this program have complex and expensive medical needs which non-specialized hospitals have difficulty caring for. Often they refer patients to children's hospitals where they can get the specialized care. This leaves children's hospitals and their pediatric providers dealing with a huge share of the Low medical reimbursement rates for pediatric care. Most children in this program are eligible for medical 70% are children of color and many reside in rural and underresourced communities. They are some of the state's most medically fragile, with conditions like cancer, sickle cell disease, cystic fibrosis, severe burns, cerebral palsy, and congenital heart disease. SB 424 will help these babies and children. My witnesses today are Nancy Netherland, parent of two children and founder of Kids and Caregivers. She will be introduced by Anne Louise Kuhns, President and CEO of the California Children's Hospital Association, who will also be available to answer technical questions, and Dr. Carlos Lerner, Medical Director for the Pediatric Medical Home program at UCLA Mattel Children's Hospital. Thank you, Madam Chair.

Thank you very much. Next person, our first person.

Thanks, Anne Coons, President and CEO of the California Children's Hospital Association. As the Senator said, I'm here to answer questions, and I'd like to yield my time to Nancy Netherland, who's a parent of two children who've been served by the CCS program.

Thank you. Welcome.

Thank you. Good afternoon. Chair Eggman and Members of the Senate Health Committee. My name is Nancy Netherland and I'm the mother of two children living with medical complexities. I also serve as the Director of a caregiver and parent engagement project for the California Children's Trust, and I sit on the California Medicaid Children's Health Advisory McHaP and the CCS Monitoring and Oversight Committee. I want to thank you for the opportunity to express my support for SB 424. The importance of SB 424 in CCS is front of mind. Last Friday, we spent the entire day with pediatric specialists, a gastroenterologist, a rheumatologist, immediately followed by extensive labs and a five hour stay in the UCSF Pediatric outpatient infusion center. I was once again deeply grateful that my daughter Amelia's care was covered by CCS. Amelia was born without prenatal care at 32 weeks, opiate exposed with cardiac and pulmonary problems. She spent the first weeks of her life in the NICU. When our social worker called to say that million needed a Foss to adopt home that could care for a premature infant, withdrawing from opiates presumed to be blind and severely developmentally disabled, we said yes. We said yes in part because we knew that CCS would ensure access to and authorization of the specialized care Amelia needed. Today, Amelia is 15. She loves horses, anime and ramen and lives with a rare, complex systemic autoinflammatory disease, as well as IBD, asthma, intractable migraines, bashette's disease, add and learning disabilities. Amelia, who is incidentally not blind and plans to attend college, has a care team that includes over 25 medical subspecialists. Amelia requires monthly infusions, regular hospital stays, extensive and expensive home medication regimes, regular labs, frequent specialty care visits, eD admissions, physical therapy, nutrition services, integrative pain management, and a lot of procedures, all requiring timely access to specialists to keep her healthy. We are lucky. We're lucky because ccs and the quality of care Amelia receives has allowed her to experience many moments of wellness, and with that, the magic of childhood, including the recent Delight of being well enough to shop for a dress for her first high school dance. With the passage of SB 424 and greater investment in the system of care she and other children rely on, there'll be better access to breakthrough drugs and to timely and specialized care. Passing SB 424 can and will ensure access to the specialized care coordination, support services and pediatric specialty care families like mine depend on. Thank you so much.

Thank you. And thank you for saying yes.

Thank you so much. Good afternoon, chair Eggman and Members of the Committee. I'm Dr. Carlos Lerner. I'm a California children's services panel physician and I'm Professor and Vice Chair of pediatrics at Mattel Children's Hospital, UCLA. I also have the honor of serving as President of the Children's Specialty Care Coalition, which is a nonprofit advocacy Association that represents 18 pediatric specialty medical groups. Our mission is to ensure that children with complex Healthcare needs have timely access to equitable health care. There are over 350,000 children in California that are considering medically complex children like Amelia that are expected to double over the next decade. The majority of them depend on CCS and the specialists for their care. I want to share with you what our Members have been experiencing up and down the state regarding access to specialty medical care. This year, our organization completed a survey of our Members to help develop a full picture of this access crisis. In 12 of the 15 specialties we asked about, the average weight for new patients exceeded network adequacy standards. For some specialties, the weight is even more extreme. For a developmental specialist, the average weight is over three months. For a genetic specialist, it's over four months. In some regions, such as rural areas, the waits can be much longer. These long waits to see a specialist can be agonizing for families and a health hazard to their children. I've witnessed this directly with my own patients. At the root of these access challenges are difficulties in recruiting and retaining pediatric specialty physicians. Medical is the insurance for the majority of children across the state, but it pays far less than Medicare for comparable services. Rates for CCS physician services have not been adjusted in over two decades. The effects of this Low reimbursement is inequitable care for our children, with fewer and fewer doctors choosing careers in pediatric specialties. In our California survey, our physician groups reported an average recruitment time of at least one year for nine pediatric specialties, with some positions vacant for over two years. With a shortage of specialties and increasing care needs, many of our specialty physicians are overbooked and overworked, leading to burnout and further losses to our specialty workforce. Additionally, many of our organizations expect a high number of specialist retirements in the next few years. In sum, chronic underfunding has slowly eroded the ability of CCS providers to ensure an adequate network to meet the demand for services of our children. SB 424 is vital to ensure that the CCS program continues to meet the needs of CCS children and their families. I respectfully ask for your aye vote. Thank you.

Thank you very much. And let's take a quick pause, and aye think we may have a quorum and establish a quorum secretary, if you could call the roll.

[Roll Call]

Thank you very much. We have a quorum. All right. Anybody else here to speak in support of this Bill? SB 424, please come forward now. Just name an affiliation, please.

Kelly Brooks, on behalf of the California Association of Public Hospitals and Health Systems here in support.

Thank you Nora Lynn with Children Now in support.

Katie Layton with the Children's Specialty Care Coalition, proud to co sponsor the Bill and here in support.

Erin Taylor on behalf of Memorial Care Health system in support.

Bryce Dockerty on behalf of the American Academy of Pediatrics California in support.

Thank you very much. Okay, now is the time for opposition again. You have six minutes total.

Good afternoon. Chair and Committee Members Linnea Koopmans with the local health plans of California, which represents the 16 local medical managed care plans, including the county organized health systems that provide integrated care to CCS eligible children through the whole child model. LHPC has an opposed and less amended position on this Bill because it prohibits expansion of whole child model, including for county organized health systems that will be expanding into new counties in 2024. The whole child model began as a small pilot program that expanded to other COS counties through SB 586 in 2016. One of the goals of SB 586 is to improve coordination and integration of services for children enrolled in the CCS program to treat the whole person or the whole child, including care for their CCS eligible condition, other health and behavioral health services, and to address social drivers of health. Since SB 586 was passed nearly seven years ago, County Organized Health Systems that operate whole child model have developed expertise in serving the CCS population maintained close connections with the families of CCS children through both case management and regular family Advisory Committee meetings successfully contracted with the providers that serve these children, including the children's hospitals and specialty care centers, and have continued to coordinate closely with their counties who have an ongoing role with respect to CCS eligibility. An independent evaluation of the whole child model program, which assesses the overall impact of the implementation of whole child model, was recently released by DHCS. The results of the evaluation are clear that the whole child model meets the goals of maintaining access to primary and specialty care for the CCS population, has maintained or improved Member satisfaction. As with any program, the evaluation also identifies opportunities for improvement or for further investigation, both in wholechild model counties and CCS classic counties where CCS is not carved into the plan. But the overall findings demonstrate the early successes of whole child model SB 424 includes many different components to modernize CCS and address provider financial concerns. LHBC does not object to those proposed changes. Our opposition is predicated on sections 8 and 9 of the Bill, which would prohibit any expansion of whole child model. We look forward to working to continuing to work with the author and sponsors to address our concerns. Thank you.

Thank you very much. Next person, please.

Thank you, Madam Chair Members. Trent Smith. On behalf of two of the LHPC Members, Central California alliance for Health and Partnership. Health associate. Our remarks with the previous speaker. Thank you.

Thank you very much. Anybody else here to speak in support or opposition of this Bill, please come forward. Now seeing none, let's go to the phone lines. Moderator, there are any callers in the queue.

Thank you. If you would like to testify. I think we're on SB 424 still.

Yes, SB 424, that's correct.

Real good. Okay, anybody for SB 424? If you'd like to testify at this time, please press one followed by zero. One followed by zero. Line 41, please go ahead.

Good afternoon, Madam Chair and Members. Nicole Wordelman, on behalf of the children's partnership and support.

Thank you very much. Next caller, please.

Line 56, you are open. 56, please go ahead.

Thank you, Madam Chair. Cher Gonzalez, on behalf of the Hemophilia Council of California, in strong support.

Thank you very much. Next caller, please.

Line 61, you are open.

Hello, Daniel Sanchez Children's Hospital, Los Angeles. In support of SB 424. Thank you.

Thank you very much.

One more final reminder. Please press 1-0 if you are in support or opposition to SB 424. And line we have one more with an operator. One moment, Madam Chair, and we'll go to line 43. Line 43. Line 43, can you hear us?

Adam Darren, Leukemia and Lymphoma Society in support.

Thank you very much. Next caller if there is one.

58, please go ahead. Line 58, you are open. Line 58 one more shot. Would you like to testify? Your line's open? They're not responding. That has exhausted the queue.

Thank you very much. Okay, now we would bring it back to the Committee for any questions and or comments. Senator Roth?

Thank you, Madam Chair. I guess my question maybe could be directed to the local plans that we're opposing, at least in part, unless amended. And my first one is, how do you ensure network adequacy in this whole child model situation? Perhaps you covered it, but I'm concerned about, given the vulnerable nature of the children that are serviced by the CCS program, I assume many of the conditions require highly specialized and trained healthcare providers, including physicians. And some of the counties that are in the whole child model may or may not have those kinds of facilities and those types of highly skilled providers available.

Yeah. So I'll focus my comments on the whole child model plans that currently operate in the program and will be expanding into 12 additional counties in 2024. So prior to the implementation of whole child model which was staggered. Beginning in 2018, there was a very rigorous readiness process that occurred with DHCs where network adequacy had to be demonstrated, including contracts with CCS paneled providers that provide this highly specialized care, to your point. So there is network adequacy. That's something that DHCs monitors on an ongoing basis. And I think one data point to pull out from the whole child model evaluation is that actually 90% of specialty care visits for children enrolled in whole child model were with CCS paneled specialty care providers. So I hope that answers your question. But it is a process that DHCs goes through with the plans to ensure that there is an adequate network to serve those vulnerable children.

Thank you. And maybe the answer to this question is wrapped in the answer to the previous one, but if not, you could highlight it for me. Apparently there was a recent study that came out. I've not had an opportunity to review it. You referenced it in your earlier comments. And so with regard to that study, what does the study or do the studies reflect regarding the percentage of children enrolled in the CCS program or receiving care by CCS providers in whole child model counties? What is that percentage versus the percentage in non.

I'll have to get back to you on that one. And actually, it's probably a good question for DHCs. The evaluation was previewed with a number of stakeholders, and I know also with the Legislature prior to its release, and so we got some high level data points. But the full evaluation was just released a few weeks ago and is over 600 pages. So I can follow up with that question or you can direct it to the Department, but I don't.

Well, I will. Do you think the answer to that question, though, will be relevant to the decisions that we're making today?

Yeah, I do. And I mean, I think the top line conclusion of the evaluation is really that the children enrolled in counties with whole child model kind of the experience in care and access to care was sort of equivalent or better than that in CCS classic counties. And I think could point to a number of kind of findings or conclusions from the evaluation to illustrate that. Like I mentioned, I think there's also a number, to be candid, there's a number of areas where the evaluator indicated that there should be a greater look at from both DHCS and on both the whole child model side and CCS in the CCS program. So happy to have a follow-up conversation with you in more detail to kind of talk through some of those. You know, I think at a high level, we feel like it demonstrates the success, at least early success, of whole child models.

Well, I think the reason I'm asking is some of us obviously want to make sure that there's a continued emphasis on moving these families and these vulnerable children to CCS qualified or specialized providers, and a disincentive to keeping the families and the children back inside the system in some other way, caring for them in some other way. And that's why the report will be. I'd be very interested in reading the report when I receive it and taking a look at the one percentage compared to the other percentage, because that may, in fact, tell the tale. I'm not going to dominate the questioning anymore. I appreciate your responses. Thank you, Madam Chair.

Thank you. Thank you very much. Anybody else wishing to weigh in on this? Okay. And thank you, Senator, for working with the Committee. And there was one amendment you didn't take. But I understand that you're going to continue to work on this issue, and I know you to be a thoughtful person who will continue to get this right, because we are talking about the state's most vulnerable children and we really need to. And again, my spouse is not a child, but incredibly complex medical needs. And I know what it's like to have to try to work with a whole team of specialties and how challenging it is to be able to find help in a very complex system. Okay. Thank you. This be at the time for a motion, Senator? Motion is SB 424 moved by Senator Ross, and that is a do pass, is amended to re refer to the Committee on Appropriations. Secretary, would you like to close, Senator? Sorry.

Thank you very much, Madam Chair. I appreciate your comment and the proposed amendment, and we're going to keep working on that issue, of course. But all in all, we just want to make sure that these children get the specialized attention that they need and that they deserve, and that's our goal. So aye appreciate an urge an aye vote. Thank you.

Thank you very much, secretary, please call the roll.

[Roll call]

[Roll call].

All right, that Bill has enough to get out, but we'll hold the roll open for absent Members. Thank you very much, Senator.

Thank you, Madam Chair. And Members.

All right. I think I see Senator Becker in the room. He is here for SB 582.

Yeah. You can do it. Sure. You can do it? Okay. All right.

Do you want to do consent?

Good afternoon, Madam Chair and Members. Let me first start by saying I'm accepting all the Committee amendments. This Bill is designed to protect healthcare providers, including small doctors practices and community clinics, from price gouging by their technology vendors. It's a little technical, so I'm going to go with some explanation.

Back in 2021, SB 133 established the California Health and Human Services Data Exchange Framework, which is intended to enable real-time exchange of patients' medical data between physicians and other healthcare entities in order to improve patient care and reduce costs within the healthcare system. The data exchange framework builds on federal rules which require all actors in the healthcare system to allow their access to the patient data to other providers and prevents any of these entities from interfering or discouraging the exchange of patient data.

Unfortunately, we are seeing examples where electronic health record vendors appear to be creating barriers to achieving this real-time exchange by charging unreasonable fees. Healthcare providers are heavily reliant on their technology vendors to enable these data exchange interfaces. If their vendors fail to provide the support or charge an excessive amount for it, they have very limited options because it's very expensive and time-consuming to switch to a different vendor.

Technology's vendors can take advantage of this dependence by charging unreasonable fees, including cases where vendors have required fees as high as tens of thousands of dollars per position physician for the required support. Since compliance is required in state law, physicians face the daunting choice, pay the fees, fall out of compliance, or take on a huge project cost to switch. If we want to achieve the benefits of seamless sharing of data, we need to make sure it's easier for healthcare providers to comply by preventing unfair practices.

Now, I'm not against technology vendors making a fair profit with many of them in my district. We just want to make sure they don't charge unreasonable fees. But what is unreasonable? Fortunately, the Federal Government has already defined rules of governing what kinds of fees are reasonable or not for technology related to the federal health data sharing requirements. And this Bill just requires those same rules to apply to additional data-sharing requirements from the state's data exchange framework.

I thank the Committee for helpful amendments that clarify how the federal regulations related to regional fees would apply to California's data sharing requirements. The original Bill in 2021 also required the main parties involved in data sharing to sign a data sharing agreement to govern how data is shared. It did not include technology vendors in this list of parties required to sign the agreement, even though technology vendors are crucial to implementing data sharing and often have control over shared data.

After some more helpful Committee amendments, the other part of my Bill asked the stakeholder group that was set up to develop the detailed data-sharing agreement to determine whether and how it would be appropriate to require vendors to be part of this agreement. If so, it will require the technology vendors to be signatories of the agreement within 12 months of those requirements being finalized.

With these two fixes, SB 582 will ensure that unreasonable vendor fees do not become a barrier to successful implementation of the data share exchange framework and to the gains in patient care that medical data sharing will unlock. And with that, I strictly ask for your Aye vote. Today we have David Ford from the CMA here to testify.

Thank you, Mr. Ford. And again, six minutes per side.

Thank you, Madam Chair. And Members, as was stated, my name is David Ford, the Vice President of Health Information Technology for the California Medical Association. We are the sponsors of SB 582. I'd like to thank the author for bringing it forward and the Committee staff, as was referenced, for doing some pretty extensive work on this Bill to help us refine the language. On that note, we know there are still some concerns out there about some of the definitions in the Bill.

Unfortunately, we have stakeholders that have given us directly conflicting input on how to fix that problem. So we couldn't quite fix that in time for this hearing. But this Bill has another stop in judiciary, and then, of course, we'll continue moving on after that. So we want to keep working on that one piece that's important.

So just to pick up from what Senator Becker said, we've seen this over and over again, actually, with small practices, through meaningful use, into MIPs, into federal information blocking, and now into the data exchange framework. We continue to put these requirements on physicians that require them to use their electronic health records to make data available to patients and to other providers. And we always stop short of looking at the technology itself, and it does create problems.

And I'll just quickly use one data point, because Senator Becker covered the Bill very well. Just before I came over here, in fact, about 10 minutes before I walked over here, I got the results of a physician survey that CMA just did of small practices in underserved communities asking about their concerns about data exchange. It likely comes as no surprise that two-thirds of the physicians listed as their top concern about data exchange. It's cost-prohibitive. This is an issue.

It's an issue that comes up over and over and over again. And as we are telling physicians, you must do data exchange, we have to really look at the impediments that are keeping them from doing so. And that's what this Bill is trying to do, is create a process, whereas we create this governance structure on the state level over health information exchange.

We're giving them some ability to review these costs and really give physicians somewhere to go to look for help. With that, I ask for your Aye vote.

Thank you very much. Anybody else in the room here to speak in support of the Bill?

Kim Stone, Stone Advocacy, on behalf of the California Orthopedic Association, in support.

Thank you.

Priscilla Quiroz on behalf of the California State Association of Psychiatrists, in support.

Thank you.

Good afternoon. Katie Van Dines with Health Access California. We don't have a position with the Bill, but I'd appreciate working with the Committee and the author on amendments to clarify that the reasonable fees will be sufficient to collect and exchange the data required by the Health Information Exchange and the data sharing agreement. Thank you.

Thank you very much. Okay. Seeing nobody else approaching the mic. Opposition?

Thank you, Madam Chair and Members. Vanessa Cajina, on behalf of OCHIN and the California Telehealth Network, in respectful opposition.

Thank you very much. Anybody else speaking in opposition today? Okay, then we'll go to the phone lines. Moderator, if you're there, open up the phone lines. For anyone support or opposition to SB 582, just name and position.

Thank you, Madam Chair. And as she stated, if you are in support or opposition to SB 582, please press one followed by zero. One followed by zero at this time. One more reminder. If you are in support or opposition to SB 582, please take this opportunity and press one followed by zero. And Madam Chair, nobody's queuing up.

Okay, thank you. We'll now bring this issue back to the Committee. Any questions, comments? Bill's been moved by Senator Roth. And we thank you for your work on this, Senator Becker. And it sounds like you'll still be continuing to work with the opposition. Try to hammer out some of those last details to make sure people can have the exchange and the billing not be onerous. Would you like to close?

Exactly. And with that, respectfully ask for an Aye vote.

Thank you very much. Secretary, please call the roll. And the motion is do pass, as amended, and rerefer to the Committee on Judiciary.

[Roll Call].

Bill has seven votes; is enough to get it out, but we'll hold the rolls open for Members to add on. Thank you very much, Senator Becker. Our next bill up is Senator Skinner with SB 598. If you're ready, ma'am. If there's a motion for the consent calendar, we could do--all right. The Senator--Roth. Move that again. He's quick on the draw. Senator Menj--or Wahab, maybe next time. And again, to repeat the measures on consent that SB 10: Cortese, SB 502: Allen, and SB 639: Limon. Secretary, please call the roll.

[Roll Call].

Seven, zero. That has enough to get it out, but we'll hold the roll open for absent Members. Senator Skinner, please present.

Thank you so much, Chair and Members. I'm presenting SB 598, and before I describe the bill, I will indicate I am happy to take the Committee's amendments that are outlined in the analysis. So I'm taking all of those.

And we thank you for working with the Committee, and we want to thank the Committee staff for their very hard work on this bill.

Absolutely. Appreciate it. Now, insurance companies commonly--maybe not commonly--but at times require a medical provider to get prior authorization before they can deliver care or treatment to their patients. Now, at certain times, that's appropriate, but there is an overuse of it. It is now basically where almost any activity that the doctor wants to engage in for their patient requires this prior authorization. That practice can harm patients. Why?

Because it can delay necessary and often time-sensitive care, which then, if it does, can result in an otherwise unnecessary hospitalization or other complication of the treatment. Additionally, patients will often get frustrated because what their doctor has recommended to them, they can't follow yet, and so they can give up on treatment. So sometimes this prior authorization is even just when you're continuing something that was previously approved.

But since it's then in limbo--and of course limbo, I don't think the church is--that phrase is probably thrown out, but I'll use it anyway--the patient will then, in effect, get frustrated and give up on their, abandon their treatment, which, of course, can also add to complications.

Now, the American Medical Association surveyed their members, and the results of that survey around this practice is that 94 percent of the physicians reported delays in care, 80 percent reported abandonment of treatment by their patients, 25 percent reported unnecessary hospitalizations because of the delay, and a good number reported different, other impacts to the patient's health and negative outcomes. So SB 598 makes two key changes. It respects the fact that prior authorization can be very necessary and helpful in terms of keeping costs down.

And it gives a one year prior authorization exemption to providers who practice within in health plans guidelines and follow the requirements for treating patients 90 percent or more of the time. It also requires insurance prior authorization reviewers to have the same medical expertise as the provider they are reviewing. So now let me bring my witnesses in support.

I've got Vivian Gonzalez, who wrote a op-ed in CalMatters for her personal experience with her father, who had cancer, and Priscilla Quiroz, who is from the Association of Child and Adolescent Psychiatry.

Thank you very much. Go ahead.

Good afternoon, Madam Chair and Members of the Committee. My name is Vivian Gonzalez. This is my mother, Stella Gonzalez. We lost our father to metastatic melanoma, a vigorous form of cancer, April 27th, almost a year ago. When doctors identified a tumor growing in my dad's lungs in August, we knew that any chance we had at beating his cancer would be rooted in the team of specialists handling his care and taking swift action. But my dad's health plan made that impossible.

Virtually every treatment test his doctor said he needed required prior authorization. Before my dad's treatment could even begin, his doctor struggled to get approval for a biopsy that would detect early signs of cancer and provide more accurate diagnosis. Finally, after receiving approval and getting an appointment scheduled ten weeks later, diagnostic testing showed that my dad had metastatic melanoma. He was referred to an oncologist specialist, where again there was a delay in obtaining approval for further diagnostics and treatment options.

I vividly remember spending three hours and a half one day in March trying to request appeals of the insurance denials of an MRI and PET scans requested by his doctors. This is my folder of all my communications back and forth with that. Four weeks later, a PET scan finally received--showed the cancer had spread into his adrenal gland, hips, and further into his lungs. His team of doctors kept our spirits high and developed an immunotherapy treatment plan. We were thrilled when my dad's treatment was transferred to a state of the art hospital offering specialty care and trials for metastatic melanoma. I'm sorry.

It's okay.

Thank you. Thank you. But every new treatment, recommendation, or scan was met with an obstacle course of prior authorization denials, which we appealed and ultimately approved--that were approved by the insurance company. This led my family and I to believe that their goal was not to provide my dad with the care that he needed, but to delay his treatment and protect the profits. It certainly wasn't to provide my dad with the care he needed to fight his cancer.

Time is your most precious resource when it comes to cancer, and I was spending my time the last few months of my father's life fighting with the insurance company. We held out hope with his doctors, tried to get him into clinical trials that would get him immediate treatment rather than go through these authorization delays. We had experience, but the MRI of his cancer had spread and revealed that it had led to his brain, which would no longer qualify him for the clinical trial.

We didn't give up. We got a referral again for him to begin radiation therapy. The referral was denied, appealed, and overturned. It was already too late. My dad ended up passing away April 27th in 2022. Nobody could have experienced the stress, frustration, and pain we went through. That is why SB 598 is so important.

It allows patients like my dad to get treatments they urgently need without unnecessary delays, and will fix the process to allow physicians to provide treatments and services based on what we the patients need when they need it. Prior authorization delays hinder my father's care options with health. Please pass SB 598 to stop this terrible practice. Please vote yes on SB 598. Thank you.

Thank you very much for your testimony, and we're very sorry for your loss. I know anniversaries are hard, but I see by your folder that you did everything you could and you're still fighting for your dad.

Absolutely. Thank you.

Thank you very much. Is there another witness, please? You have about two minutes left.

Priscilla Quiroz, here on behalf of the California Academy of Child and Adolescent Psychiatry, proud cosponsors of SB 598. Prior authorizations have expanded new and brand name medications to generic medications, causing increased daily burden on the entire medical system, including families. Providers had had to hire staff to process prescription prior authorizations, increasing health care costs, which ultimately limits the delivery of health care available for all. In addition, now prior authorizations are frequently for generic medications that cost less than 20 per month.

Although that means some will buy out of pocket, not all can do so. This is an abusive, stalling process that limits the care provided to everyone. Psychiatric access to care is a huge problem throughout California. Children adolescents face serious and dangerous wait times to access to care, then face further delays in initiating care due to prior authorizations. In addition, every year, insurances require renewing authorizations for necessary medications that have safely been taking for a long time.

Excessive prior authorizations lead to worsening of crisis: hospitalizations, children missing school, parents missing work, and harm to patients. Prior authorizations disproportionately affect lower income individuals because clinics that serve populations do not have funding to hire staff to process PAs, and those families do not have funds to purchase even generic medications out-of-pocket. Insurance companies use artificial criteria for requiring PAs. For the pediatric population, they frequently cite that medication isn't FDA-authorized for treatment.

Unfortunately, most medications are not authorized for children, especially considering psychotropic medications, treatment for chronic pain to children, and treatment for rare conditions. This lack of authorization is not related to safety or effectiveness, but rather a lack of funding to complete FDA authorizations, especially for generic medication. Prior authorizations begin as a cost control, but have been abused by the point of increasing health care costs and becoming a dangerous burden barrier to care. For these reasons, we respectfully ask and urge your aye vote today, and on behalf of the California State Association of Psychiatrists are also in strong support.

Thank you very much. Others speaking in support today, just name and affiliation, please now.

Madam Chair and Members of the Committee, Brandon Marchy with the California Medical Association, proud sponsors of the bill. Thank you to the Committee and staff and you for working so hard.

Kim Stone, Stone Advocacy, on behalf of the California Orthopedic Association, in support.

Thank you.

Stephanie Morwell, on behalf of the Advanced Medical Technology Association, here in support.

Thank you.

Ryan Spencer, on behalf of the California Podiatric Medical Association, in support.

Thank you.

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

Thank you.

Dean Grafilo, on behalf of the California Life Sciences, in support. Thank you.

Thank you.

Le Ondra Clark Harvey, on behalf of the California Access Coalition, in support.

Thank you.

Bryce Docherty, on behalf of the California Ambulatory Surgery Association, the California Academy of Family Physicians, and the California Society of Anesthesiologists, all in support. Thank you.

Thank you.

Katie Layton, on behalf of the Children's Specialty Care Coalition, in support.

Thank you very much. Okay, seeing no other supporters in the room, now it's time for opposition. Please come forward.

Good afternoon, Chair and Members. Bill Barcellona with America's Physician Groups introducing our Board Member, Adam Solomon.

Thank you.

Good afternoon, Chair and Members. My name is Adam Solomon. I'm a Board Member of America's Physician Groups and the Chief Medical Officer of the MemorialCare Medical Foundation, part of an integrated health system in Southern California which takes responsibility for the quality and cost of care for over a quarter million Californians. I'm also a board-certified internal medicine physician. One of the things that I noticed at the start of my practice 26 years ago was the variation in the approach to care by specialists.

Now, years later, even with the dramatic increase in high-quality research and the growth of evidence-based medicine, I see this issue persist. To me, the North Star should always be what is best for the patient. Many patients assume that when a doctor tells you that you need a procedure, it really needs to be done.

But a 2014 study by the Harvard Medical School and the Commonwealth Fund found that in one year, between 25 and 42 percent of Medicare seniors received one of 26 tests or treatments that have been determined to have no benefit or to be outright harmful. Prior authorization is a tool to help reduce the likelihood that patients receive such unnecessary or harmful care. I want to clear up some common misperceptions about prior authorization. Firstly, prior authorization rarely causes delays.

There are strict and specific time limits that organizations must comply with in order to finalize their requests. Those turnaround times are regularly audited, carefully monitored, and must be reported at least biannually, with some plans auditing us monthly. We process about 750,000 prior auth requests per year, with one-third approved within a day and our average turnaround time is below two and a half days.

Secondly, the number of denials is very, very low, and in most cases, those denials tend to be for specific procedures that have been found to be of marginal value to the patient or that catch a referral to a provider or location that is not in the network, saving the patient from undergoing unnecessary procedures or being impacted by high out-of-network costs.

Just as you would expect the pharmacist to catch an errant prescription with the wrong strength, prior authorization provides a second look to confirm that the service being requested matches the evidence. With the implementation of the Office of Health Care Affordability, we also are subject to growth caps, cost growth caps established by the state government. Prior authorization review is a key element in meeting those state mandated goals so we can ensure that patients are receiving the most cost-effective and evidence-based care.

Is your family member better off going to a doctor that wants to avoid another doctor reviewing their recommendations? To me, the patient should come first. Thank you. Both Mr. Barcellona and I will be available for questions.

Thank you very much. Anybody else speaking in opposition to this bill today? Please come forward.

Madam Chair and Members, thank you very much. Steffanie Watkins, on behalf of the Association of California Life and Health Insurance Companies. First, I'd like to thank the Committee staff and yourself, as well as the author and sponsors. We've had multiple conversations as this bill we've seen before. Unfortunately, we are here today in opposition. SB 598 is a complicated bill that will regrettably increase the cost of health care, lead to poor patient outcomes, consumer confusion, and increased administrative costs.

This bill contains a number of major provisions. I will primarily be addressing the provisions related to prior authorization. The prior authorization kimono of the bill will obstruct the ability of my members to apply common sense checks and balances in health care. Health plans and insurers work diligently to ensure that enrollees and insurers are getting the right care at the right time from the right provider. Prior authorization is key component to that.

In recognition of the need to streamline the process, many health plans and insurers are currently implementing their own enhanced prior authorization programs to help ease the burden of providers and enrollees. Unfortunately, the one-size-fits-all mandate outlined in SB 598 will disrupt those efforts and harm the good work that has been done to date to those in a safe and logical manner. The scope of 598 is concerning.

This bill gives specified providers a free pass for any oversight of clinical decisions for a period of one year. At the end of that one year, health plans and insurers would only be allowed to review a maximum of 25 cases across all product types. This is hardly representative sample to ensure our enrollees and insured are receiving the right care. Under 598, prior authorization is weighed for all services and most drugs rendered by the provider.

The waiver would even apply to services that are associated with high-risk fraud, waste and abuse, and negative side effects. SB 598 offers very little to ensure that the rate of fraudulent and wasteful care does not increase during the one-year look back period. Also, in our estimation, we believe that SB 598 will actually increase the cost of health care by increasing the number of unnecessary services that will flow through the system.

It should be noted that the bill allows providers to count any modification of a prior authorization if it is ultimately approved as a part of their 90 percent approval rate, which is a standard for them qualifying for the program. This is especially concerning because you could have a provider whose prior authorizations are often modified based on compliance with clinical care guidelines, yet because the PAs are ultimately approved after the changes are made, the provider can use those as a part of their 90 percent standard to qualify for a gold card.

Ultimately, that means on a go forward basis, none of those modifications would be identified, leaving us to wonder how many patients will be put at risk, how many unnecessary services will be performed, and how will enrollees and insurers handle the potential increase in premiums due to the additional cost into the system.

And to that point, we currently do not have a Chipper analysis on this bill, so it's incredibly difficult to qualify what the exact cost increase to premiums would be for payers. For those reasons, we are opposed to SB 598. While we think there is a pathway to have a productive policy conversation, we look forward to potentially having that. At this point in time, we think this bill goes too far.

Thank you very much. Others speaking in opposition at this point now, just name and affiliation.

Madam Chair and Members, John Wenger, on behalf of America's Health Insurance Plans, in opposition.

Madam Chair and Members, Nick Louizos, on behalf of the California Association of Health Plans, in opposition. Thank you.

Alison Ramey, on behalf of the Pharmaceutical Care Management Association, in opposition.

Thank you. At this point, we'll go to the phone lines. Moderator, if there are any calls in the queue, and at this point, just name, affiliation, and position on the bill.

Once again, press one then zero on your telephone if you have opposition or approval for it, this bill. One moment. We'll go on to line number 56. Please go ahead.

Good afternoon, Madam Chair. Cher Gonzalez, on behalf of my clients, the Association of Northern California Oncologists, otherwise known as ANCO, as well as the Medical Oncology Association of Southern California, otherwise known as MOASC, in support.

Thank you very much. Next caller, please.

We will now go to line number 66. Please go ahead.

Thank you, Madam Chair and Members. Alex Khan, on behalf of the California Chronic Care Coalition, in support.

Thank you. Next caller, please.

Next caller is line 45. Please go ahead.

Thank you, Madam Chair and Members. This is Sandra Poole, on behalf of Western Center on Law and Poverty, in support.

Thank you. Next caller, please.

Our next caller comes from line number 53. Please go ahead.

Madam Chair and Members of the Committee, Randall Hagar, Psychiatric Physicians Alliance of California; are strongly in support. Thank you.

Thank you very much. Next caller, please.

Our last caller is from line number 69. Please go ahead.

Madam Chair and Members, Bob Ackerman, on behalf of California Radiological Society and the California Society of Pathologists, in support. Thank you.

Thank you very much. That's all the calls, Moderator?

That is correct. No further calls.

Okay. Thank you very much. At this time, we would bring the bill back to the Committee. Questions? Comments? Senator Grove?

Thank you, Madam Chair. Tough issue for me. I think the pendulum swung when we did prior authorization a few years ago. There were medical providers that were obviously taking advantage of certain things and getting carte blanche. And when you brought this bill forward, I've had several medical providers contact me in my district requesting my aye vote on this bill. And then I've had several of my plans and pharmacies saying, 'please don't do it, this causes chaos,' so on and so forth.

I think there's a happy medium someplace. But I do want to tell you that I have concerns. I do think that we need the prior authorization in some cases, but then I also know that doctors take an oath to do no harm and that they should make sure that the patient is taken care of, and especially, like the witness talked about, her father, that did not get the timely medication needed for cancer treatment, which is something that desperately needs to be treated in a timely manner.

I have a few concerns, and I just want to address them with you to see if it's something that could be worked out. So let's just say the bill passes and a doctor issues a prescription. The doctor issues the prescription, the patient or the member takes it to the pharmacy, and the pharmacy issues the prescription based on the prescription issued by the doctor. And then I realize it's only ten percent because 90 percent of the prescriptions are authorized even for--preauthorized by the insurance company.

Who's responsible for that? Does the pharmacy eat that cost because the plans aren't going to pay for that or does it go back to the doctor? I think there's a gap there, if that makes sense, unless there's something in the bill that I missed.

Well, this doesn't directly answer the question, but I'll come back to your question. There's tiers of prescriptions and their Tier Four in the bill is exempt. Tier Four tends to be the most expensive and specialty drugs, and it is exempt in this. Now, if an insurer refuses to cover the cost of the prescription, usually the pharmacy--let's use the example of they refuse to cover the cost of the physician.

Most of us, when we go to the doctor, we get something in advance from the doctor indicating that you, the patient, are responsible for the costs that insurance doesn't cover and that, in effect, your agreement to that is part of your agreement to take services from that doctor. Now, I can't stand before you and tell you that every pharmacy does the same thing, but I would imagine that most pharmacies would then bill the recipient. In other words, the person who received the medicine.

Okay, thank you for that. There was a clarification that pharmacies were asking for, like: who would be responsible for the bill? And so if the insurance companies didn't provide it, I just want to make sure that I understand that the pharmacy would be responsible for pursuing personal payment from the member that requested or the individual that requested.

Which is usually what happens even when we're not talking about prior authorization, for example. I mean, most every dentist you go to gives you in advance, has you sign something, an agreement the treatment that there is an estimate of what insurance will cover, but there's not a guarantee, and thus you would be responsible for the difference.

Thank you, ma'am. The other question that I had--or excuse me; thank you, Senator--is some plans or member companies have 1,000 members and tens of thousands of members. I think that even on a gold carded program, 25 audit--to pull 25 records out of an organization that has tens of thousands of members is a pretty low number.

Was that a consideration that was taken when you looked at this or would it be something that you'd be willing to look at a percentage point so that there could be an adequate audit program? What I don't want to do is go back to where we were before, right?

I want the plans to be able to say, 'look, you're doing this wrong,' and they have to have an adequate audit program to do that so that the pendulum just doesn't keep swinging from right to left because this is a delicate balance in the middle and obviously lives depend on it.

I hadn't really considered whether there should be a volume metric or, as you indicated, a percent. We settled on a number, but it's certainly something that I can talk to the sponsors about whether that would be an appropriate modification.

Okay. Thank you. I appreciate that. I know you're willing to work with the opposition. Like I said, my concern is that if you've got, I don't know, 50,000 members and you get to audit 25, not 2,500 but 25, that's kind of a poor audit--to me, it's a poor audit capture there.

How about, can we have maybe the sponsor address that? Because I don't think that's quite right.

Okay. Absolutely.

Yeah. I thought it was by doctor, but that's okay. We'll go.

Yeah. Madam Chair, Senator Grove, so the 15 to 25 is based on a review of the physician's utilization during that gold card program for a year. The reason why--and the bill started off as ten to 20--we took an amendment upon introduction to move it from 15 to 25. The reason is that because those are in-depth reviews that require medical records and so on and so forth.

So if we start to increase that number, that burden that we're trying to address here for physician practices really doesn't get addressed because that would require a sit down, review of medical records, so on and so forth. And that is certainly true upon appeal. So the 15 to 25 is by physician.

Right. Not by number of members in a health group.

By physician. Okay.

I'm sorry I misunderstood that. I apologize. Thank you for clarifying that, and I think it's the last question I have. The last question I have is that obviously, the most important thing that is addressed here is life-threatening disease or life-threatening illness. I don't think anybody who's struggling with a timeline of cancer should be denied anything until they get--obviously, and I'm very sorry that that happened to your father.

Yes, ma'am.

But there's that story, which is very significant, and I'm sure other stories like it, but there's also stories on the other side where the insurance companies have found out that there have been prescriptions that have caused harm, addiction, and other things. And so I know you're going to do what you're going to do with this bill, but I would like you to consider a balance in the middle because I think the plans are making sure that they have adequate health care for their members because if they didn't, their members would leave their plan.

But I also think that doctors have and are issuing prescriptions to make sure their patients are taken care of. And like I said, they take an oath to do no harm. But I also know that there are doctors out there that may not, that may just continually reissue prescriptions, and the plans find that those things are causing more harm, which are creating other health care costs because of those prescriptions being issued.

So I get it from both sides. Both sides are, I think, looking out for the best interest of their members and the patient, which is the same person, and we've got to strike a happy medium. So I would just ask you if you would please look at the fact of catastrophic or death or imminent death or illness, terminal illness steps to make sure that--or not just terminal, but disease that can be treated, that there's a time-sensitive situation like we have in the testimony.

But then also address the issue that the plans have with regarding to the auditing, to be able to make sure that doctors are doing what they're supposed to be doing and then addressing the issue with the pharmacies have, because pharmacies, some of them are opposed because they feel like they're going to be stuck with the bill and there's nothing they can do. To go after someone else for a personally paid prescription is not a very good avenue. So thank you for listening to my comments.

Thank you very much. Senator Roth.

Thank you, Madam Chair. You know, I asked my staff to try to provide me with an insurer's PPO preauthorization list, and my staff did so. And it looks to me like it's about 100 to 125 pages, fairly small print. One of the items on the first page is anesthesia for a heart transplant. I assume there's some other issues associated with that, but I guess my question goes to the plans, since this obviously is an active insurers PPO preauthorization list. What's wrong with gold carding physician, a health professional who has an approval rate of not less than 90 percent?

Thank you, Senator. I think the question for us really is the details of how that's determined. And I know that when you look at it from the perspective of 90%, when you look at it at 10% of people will get potentially care that's not appropriate, that shouldn't have otherwise been authorized. I mean, our members have done a lot in the way of looking prior authorization.

I know that it feels like there's a lot, but some of them are simple things like, you may have a drug that's counterindicated for someone who's pregnant, so there's a prior authorization on that drug, and it's going to go through a simple edit process and a quick review. But that's a part of it to catch those instances where there's harm to the patient that may be unknown to the provider.

There's also issues on the PPO side where you sit as your own primary care physician, you are managing your own care. So you may not be aware of all of the labs that were done by one specialist, are now being reordered by another specialist, but can be shared. I mean, all of those additional costs would be borne by the system. And that's not to say any nefarious reason on behalf of the providers. It's just a simple management.

And so many times prior authorization is not meant to be punitive. It's meant to manage the system. And I think one of the most concerning parts about the bill, at least for me, is that it considers your modification. So if you're a provider, you've requested prior authorization. The plan has an edit or has caught something. You should start with 5 milligrams instead of 10 milligrams. You should start with PT instead of back surgery.

I catch that, you as a physician, modify that, make that change, resubmit it, and are approved. You get to consider that as a part of your 90% approval rating. I mean, therein lies the real medical management, where I think we provided some of you with some numbers, more on the HMO side, but there's about 30% of those modifications that are significant but very helpful to the system. And I think our concern is those will no longer be caught.

So would the plan's position on the bill change if the language in the bill provides, essentially, that approve not less than 90% of the prior unmodified authorization requests?

I think we'd still have concerns. I think there's an interesting amendment that was taken that has plans look at services that have a 95% approval rating. That was a most recent amendment that was in conjunction and kind of in line with AHIP, which is our national organization at AMA.

But that still involves modifications, potentially. What I'm saying is you have a situation where the bill says instead 90% or more prior unmodified authorization request. So you have a physician that 90% or more of the time is in complete agreement, a mind meld with the plan on what should be authorized and what not should be and what shouldn't be authorized. Wouldn't that change your position?

I think we'd fundamentally still have concerns with Gold Carding in general. I think the idea that there potentially could be 10% of edits and additional services that are driven into the system and the potential costs. I think what we'd want to see is a CHBRP analysis to tell us what that potentially could do.

On the PPO side especially, we're already the most expensive insurance that you're probably going to be able to access. If we are driving additional cost into that, especially for rural areas where they don't have an alternative, and the PPO is the only option that they have. I mean, we're continuing to look at making healthcare less affordable.

We are absolutely open to having a conversation, but I think just making that minor modification, but still having Gold Carding, I think we'd like to see some numbers and a greater analysis than what we've seen. We've had bills in this Committee and others that just make minor tweaks to prior auth that have gone to CHBRP. And so I think we are working a little bit blind about what the actual numbers are. And I think this Committee, especially, should likely be asking those same questions.

Well, the reason I'm asking is so if you have a physician in a 12 month period that submits 100 requests for a prior authorization request for approval, and consistently 90 of those request requests are approved by you. We can discuss whether they're modified or unmodified, and 10 are not, without this bill, you are requiring the physician to have authorization, get authorization on all 100 of the requests if they're the same the next year. Does that make sense?

No, it does. And I appreciate where you guys are trying to find a middle ground of whether or not... I think we would be open to conversations about reviewing prior authorization, setting a specific goal. I think the other issue is wanting to look at a specific service versus a primary care physician could do a lot of different things under their day to day activities.

I think if we're looking at, most of our members have looked at specific services and determined, based on a specific service, to remove prior authorization, versus that provider no longer has prior authorization over any service or drug they provide. I think that's the greater concern. Because those edits would no longer be caught when it comes to safety. And that's the other issue.

Okay.

Do we want to have, we do have the CHBRP, I think, in the room. Is somebody here? Darren, John Lewis. Would you like to comment on this since there's a lot of questions about the CHBRP process? Do you want to come to the mic?

Senator Eggman, we were not asked to review the bill, so we've not had the chance to pull our actuaries and faculty in to look at it. Though it is a particularly complicated question, quite different from many of the kinds of bills that we have been asked to analyze.

Okay, thank you. And that means, generally, they'll look at something having to do with prior authorization and figure out how much it'll actually cost. What he's saying is that because this is a Gold Card, so it takes into account many procedures, many different prescriptions, that it's very complicated to try to figure that out. Did I characterize that correctly, John? Thank you.

May I address the Senator's question? Thank you. As an example. And so they brought up was back pain. So there's an example of back pain patient. Most of patients who have back pain that get sent to a specialist don't get surgery. But they see the specialist, who then orders physical therapy, orders a follow up, orders an x ray, orders, potentially, some labs, orders more physical therapy, orders an MRI.

So we are now out 6, 7, 8 different referral requests, prior authorization requests. And in the end, that patient may not get surgery, and likely won't. That next patient comes and sees the patient. You repeat this four times, easily more than 90% approval rating on all of the requests. Now, this surgeon asks for a fusion, multilevel fusion on this patient. Completely inappropriate request. It's denied.

You do a random audit of this patient or this surgeon's thousands of requests over the course of the year of 25, they're likely all going to be fine, and that physician will be Gold Carded. And yet the final surgery that he recommended was completely inappropriate and dangerous for that patient to have.

I understand. Then you need to figure out a way to deal with the 10% and not have us have pre-authorization for all 100% of the cases that the physician submits to you. That's my take on it, but that's just me.

Thank you.

I have some questions I need to ask with the Chair's permission.

Go ahead.

To the groups, if we have the group still here. So what I held up was a PPO prior authorization. How does this bill impact multispecialty medical groups that are capitated?

In the same way, for the most part. The groups are delegated by the health plans to do this function. They're also financially responsible for the costs. And so if they were delegated under this bill, they would still be on the hook financially for all the charges that these physicians would be racking up. That's where we lose the medical management and we lose the cost control in the system.

Let me just boil that down. So my understanding of capitation, which is probably erroneous, and you'll correct me, I'm sure, is that a multispecialty medical group, like a hospital, I suppose, will receive, let's say, $10 million to take care of 1000 lives. A capitated payment, lump sum or quarterly or however it's paid, and you get that money to try to keep them healthy because that's in your best interest. But whether you keep the thousand lives, thousand people healthy or not, you have to service them, provide medical care, health care for the $10 million.

Right.

So it's incumbent on the multispecialty medical group to manage that money and manage that care so the lines cross or meet. The patients get the care they need at the time they need. Hopefully, you maintain them in a healthy condition. And the medical specialty, multispecialty medical group continues to remain in operation because you've not spent more than $10 million. So you do your own utilization review inside the four walls of your multispecialty medical group, correct?

Yes. That's why we have the California Delegated Model, which is different from other states. It's physicians managing the care of other physicians.

And what I'm concerned about is I'm trying to make sure that this bill avoids dictating to those inside the four corners or walls of a multispecialty medical group or medical clinic how or how not to do utilization review. Because we're dictating to you how you manage health care money you receive and how you deliver health care to those lives that you're responsible for.

Right.

And so how does this bill...

If I could address that.

Yes, ma'am.

So if you look at Section 1366.79, it states that a plan shall not delegate the requirements in this article to a delegated provider unless the parties have negotiated and agreed upon a new provision to the party's contract. So it retains the ability of a delegated provider to do what you described.

My question, ma'am, is, Senator, is the power is inherent in the plan, not the multispecialty medical group or clinic that's attempting to provide health care. And so if the contracting, it's an unequal contracting position. And if we're expecting the plan not to attempt to pressure the multispecialty medical clinic or group not to agree to a contract provision, I'm not sure that that's going to work.

That's correct, Senator. And respectfully...

I'm supporting this bill. I just am concerned about this element of it.

Yeah, I've been doing healthcare contracting work for 20 years now. The Provider Bill of Rights gives a delegated group the ability to terminate their contract with the plan if a provision, a material change, is unacceptable to them. That's the only remedy under the Provider Bill of Rights. So you terminate the relationship over a line in the sand, if you will, in the negotiation. That really doesn't help anybody in this situation, does it? We lose the medical management of the group in the delegated relationship.

The plan goes back to retaining this administrative function, and there's less oversight by physicians over physicians in the system. So that's the problem. What we see at the group level, where we take responsibility for this care in a network, is a tremendous variation in practice. What Dr. Solomon sees in his daily review of thousands of these, is that, while one surgeon does it a certain way, he'll see 20 who are in the same specialty doing it in a different way.

And this is where this extra layer of review is so important. Because we know in American healthcare, 40% of the care is subject to variation in practice, as he stated, overtreatment, unsafe procedures. That's why this is so important, to have this line of review at the medical group level from physician to physician.

Well, thank you. I see a difference between PPOs and the managed care situation. I appreciate it. Apologize to the Chair. Apologize to the author. Thank you for the clarification. I'll be supporting the bill. But as the bill moves forward, from my perspective, we need to deal with this capitated, multispecialty medical group issue, and I don't think we can leave it to the health plans to deal with it by contract because I think there's an unequal bargaining relationship between our health plans and medical groups that is not solved by this bill.

I appreciate the distinction, and I read the section because our intention in the section was to try to protect those delegated groups. But I'm certainly willing, and perhaps the sponsor could also speak to this if they have a perspective on it, to look at the points you made. Because, of course, our intent in doing that section was to protect them. But if there's an issue about that, we'd be happy to look at it. So, Brandon.

Senator Roth, so the previous iterations of the bill, again, did not have this exemption. After 2022, in that session, we met with delegated groups. A lot of those medical groups are our members as well. And we understood the actual problem, which is why when you get back to the fundamental issue, to your point, these medical groups are doctor owned, operated, and configured. Right.

So when we understand and understood the problem, the exemption went into the language, and you have our commitment to attempt to tighten that more and protect that delegated model. Right. They are closest to the patient. That is not something that we want to blow up with this bill, and that is the intent of the exemption that we can take back and strengthen in order to make that clearer.

Senator Limon.

Thank you. I appreciate the conversation. The dialogue and mine is more of a comment and a comment that leads to, I think, a struggle that I've had over the last seven years, because over the last seven years, we've been having discussions about prior authorization. And I've seen it approached, really, on a one issue by a one issue basis. And I am part of that. Like, I've had bills. I have bills. You're going to see a bill that deals with one specific thing.

And it's really difficult because this is such a big problem. And I think that one of the comments I heard that was that there's not a whole lot of evidence that this actually leads to a delay in care. And I have to tell you that the more you talk to constituents, that is very disconnected from the lived experience of constituents. So I've struggled with how do we address this as a system? I think wanting some cost control is reasonable. I truly believe it's reasonable.

I hear examples of, if the lab tests are already being done here, perhaps we could use them. I get that, and I would agree with a process that considered that. And we don't want a system that duplicates a lot of the same work. I mean, you don't want that in any particular space if it's not needed. But it is very difficult to understand what it's going to take to say, look, we've had at least a decade of having a conversation in this Legislature about prior authorization.

We've piecemailed it, and it's been very difficult. And so you have a bill like this that attempts to go broader and not just do it for one particular thing. And we want to be sensitive to the issues as the management of care. But this has become very difficult. And I think that I am now at a place where I'm not convinced, while I am an author, and I think that we have to do whatever we can.

I'm not convinced that the long term solution is to only do it by piecemeal, and that means one particular piece of care at a time. I think that that, out of necessity, you have authors like me that have had to do it, but I'm not sure that that is the ultimate long term solution.

So I share these thoughts and this feedback simply because it's something that keeps coming up and I don't know when we're going to reach some kind of understanding of what the system needs in order to bridge whatever evidence there is that this doesn't delay care to the lived experiences of so many people we represent that says it does. There is a real gap there that I think I feel needs bridging, and I've struggled with what that answer is.

I've attempted to do it in one ways, and I'm not sure that's the ultimate way. So I look forward to more conversations about this because I think we are all interested in getting it right. We are all interested in having a healthcare system that does more access and doesn't duplicate some of the cost if not needed. But, certainly, I think access to immediate care is at the core of what we're all trying to achieve.

Thank you. Anybody else? Okay, I'll say, and again, just to thank the opposition and the sponsors and the author and staff for working so hard on this. As you can see, it prompted a lot of conversations here. It certainly prompted a lot of conversations. Even when I was overseas, we were having conversations about this, and our plan is to ask CHBRP to do a look at prior auth overall. So I kind of wanted to hold back on a lot of these piecemeal bills because it does get very technical.

We have another author here with one today also. And for every time we do that, it's like Whac-A-Mole, right? You try to help this group and then it costs more on the deductible or on the other group or into the plan. So our healthcare system is incredibly complicated. And so we thank you for really trying to dig down and work on this.

I will also say I can see both sides of this, but on the sides of, again, I live with a sick person and I know the prior auth, every single time we have to renew the physical therapy. Right. You got brain cancer and neurological issues. It's not going away. So that's always approved, but it's always a waiting period. And to say that the pre auth works all the time, because we know people have procedures that aren't necessary under the pre auth system. Right. That already happens. And again, we're talking about physicians who have 90% that receive authorization. So I'll be supporting this bill. And would you like to close?

Thank you. Look, our healthcare system does cost all of us too much. It does. And so I am very supportive of trying to bring those costs down. But I will assert that health insurance interest in bringing down costs doesn't necessarily bring down the cost to you and I. It brings down the cost of what they're paying out, not to you or I. And I don't know anyone for whom treatment was improved due to their insurance company's intervention.

And for many of us, when the pre-authorization is denied, I was very impressed to hear from our witnesses that they took the time to appeal. Because for many of the plans, the process for appealing, you go onto the website to find, and the form is not readily available. There's like a 1-800 number you might have to call. You're put on hold for however long of a time. You're then directed to this, that, and the other.

I mean, it's basically designed for you to not be able to successfully submit an appeal. And then, of course, you wait forever to get an answer on that appeal. And there's good documentation of that. The insurance companies are quite, they know this. And so some portion of their prior authorization requirement is to, hopefully, discourage either the patient or the health provider from pursuing it. And then, of course, that saves them that cost, but it doesn't necessarily improve the outcome to the patient.

And I will also say that I was a bit taken aback by the comment that, well, this prior authorization is going to help ensure that, say, if you're a pregnant woman, that the prescription that you were prescribed isn't counterintuitive to your pregnancy. Well, both the pharmacist and the doctor have the liability responsibility for if they prescribe a prescription or dispense a prescription that is counter indicative to that patient.

So what added benefit that the insurer would necessarily have even all of the knowledge or the records on the patient in terms of that one? I'm sorry. That one I felt was just not even credible. There may be other circumstances where, for example, if there's two different specialists. That example that was given. Okay, fine. I can see where that is potentially relevant. But some of the examples, no.

Anyway, I didn't intend to add those things in the close, but it happens sometimes when you're presenting a bill and things are brought forward. But I commit, as was indicated, to work with the sponsors to try to address this issue of the delegated groups, because it is not our intention for them to be put at that disadvantage, and to continue to work on it. But I think that the system that we have now is not per se delivering the best care and the best outcomes for our patients. And with that, I ask for your aye vote.

Thank you very much. And this motion is do pass and rerefer to the Committee on Appropriations as amended. Secretary, please call the roll.

[Roll Call] Six.

Thank you, Madam Chair and Members, I'm presenting SB 779 on behalf of Senator Stern, which will guarantee quality care and quality jobs in healthcare and increase public transparency by updating annual data reporting for nonprofit primary care facilities clinics.

Got 6 votes, and we'll leave the roll open. Thank you very much, Senator. And I believe Senator Gonzalez, who is not chairing this Committee, is next up to represent first, Senator Stern.

Before I begin, I would like to state that the author is accepting the amendments worked out with the Committee staff that are being passed out. I would also like to thank Committee staff for their help developing these amendments on behalf of the Senator. These amendments remove the civil penalty that was previously in the Bill. Additionally, the amendments significantly narrow the data reporting. Some data elements are removed completely, while in other cases discretion is given to the Department.

The recently released California Primary Care Association compensation and benefits survey report indicated that staff turnover rates continued to climb, with rates in 2022 over 3 times higher than those of 2020. These conditions have a devastating impact on patient care, exposing vulnerabilities in our state's social safety net and further exacerbating disparities in the healthcare delivery system. Current reports do not provide the level of detail needed to understand labor trends, workforce development activities and implications for quality and equity.

Therefore, SB 779 will focus on modernizing data collection on clinic workforce and the quality of patient care. Today, I have here to testify on behalf of the Senator, Beth Melinowski. She is the government affairs advocate with SCIU California, as well as AngeLA Milan, a patient access representative with Golden Valley Health center and a proud Member of SCIU Local 521. I respectfully ask for an aye vote.

Thank you very much, Madam Chair Members Beth Malinowski, and I'm here today again on behalf of SCIU California, 700,000 Members. SE California is a proud sponsor of SB 779. Grateful for Senator Stern's leadership and Senator Gonzalez for stepping in today to present. Thank you. As Senator noted, we hope the Committee agrees that we've taken significant amendments to refine the Bill. I want to again applaud the guiding hand of the Committee.

On that note, I would like to briefly share with you SEA's perspective on this important Bill. The Bill comes down to a few things. Clinics are growing, but their data lags behind. Accuracy of clinic data will get worse without action, and we need to collect new data to better recognize the environment we're in today. The Department of Healthcare Access and Information and its predecessor, ASHPED, has a long history of annually collecting from each licensed clinic site, primary care clinic annualization report, or the AUR.

For the past decade, the number of clinics in California has grown significantly, with much of the growth being in intermittent clinic sites. Today, intermittent clinic sites do not report data directly, but under their licensed clinic they're affiliated with. This means data across two or more locations is aggregated together. This is resulting in aur data set that no longer provides accurate information of local experience and can no longer meet the needs of policymakers and stakeholders.

Because of the significant growth in intermittent sites, a trend that continues our data set will get worse. The percent of clinic sites completing the AOR is decreasing each year. Less data means a less complete picture of primary care and underserved communities. SB 779 gets us back on track by requiring data collection of intermittent sites. Additionally, SB 779 takes us a step further. With new data requirements, we'll be able to better understand the labor picture on the ground.

We'll begin to collect data on notable but not well documented trend of clinic mergers and acquisitions. And last, we'll be able to make sure that quality and equity measures at the local site level are publicly documented. Ultimately, with greater transparency and accountability, we can better inform public funding, public policy decisions that improve access to care. To YSA is proud to support sponsor SB 779.

Good afternoon, Senators. Thank you for this opportunity for me to share my story with you. And my clinic workers like me support SB 779. My name is Angela Mian. I am your dental scheduler at Outwater at Golden Valley Health centers.

Thank you in advance for your aye vote I'm going to hand it over now to Angela Milan to speak on behalf of clinic workers. Thanks, Angela. Thank you very much.

Like so many other clinic workers in my state, I love my job and I love what I do. But that's why I'm here today. Because, like our community, clinics need help to deliver on promises of our healthcare access for all. But the way things are now, lawmakers and others who care about healthcare justice aren't getting the complete picture of what's really going on. Access the state across the state, there are more than 3000 clinic clinic sites.

But nearly half of these sites are required to report information. Or rather, they have significant staffing, workforce development and how these services are being met. The lack of service information is misled to the millions of Californians that rely on our clinics. Each year, new clinics are opening up faster than levels of staff that we can be met. We can't keep providers of our facilities. We can't retain receptionists, dental assistance, medical assistance. But we need to have more workers to meet raising patients'needs.

Our clinics just opened up urgent care in Patterson, California. But in the face of high staffing, turnaround and shortages of workers, I worry we won't be able to fulfill the patient's needs. Many of the new staff leave after suffering and with the heavy workload and Low wages that we have at the moment, SB 779 won't solve all these problems we are facing in our clinics today, but they will be a major step in helping find the solution.

We will be able to see which clinics have enough staff, what clinics are doing, what to address shortage of staff and how the clinics are surrounding will help the surrounding communities around us. I urge you to stand with clinic workers and the millions of patients who rely on the support and care we provide each year. I ask you to vote yes on SB 779.

Thank you. Thank you very much, Angela. Anybody else now wanting to come forward? Just name and affiliation, please.

Good afternoon, Madam Chair, Committee Members and staff. Christophe mayor with the American Federation of State, county and Municipal Employees in support of SB 779.

Thank you, thank you. Chris Myers with the California School Employees Association and strong support. Thank you, thank you. Good afternoon. My name is Angel Valdez. I work at a clinica in Oakland and I'm a proud Member of local 10 to one. And I'm here speaking in support of SB 779.

Thank you, thank you. Good afternoon. My name is Tina Dip. I'm from East Bay. I'm from Asian Health Services. I'm a community health advocate, also a Member. SCIU 1021 on support SB 779. Thank you, thank you.

Madam Chair, Committee Members, my name is Keith Thu Mamoto with the California Alliance for Retired Americans in support of the Bill.

Thank you. Good day. My name is Miria Holder. I am a UN specialist. I process referrals at the Watson center. I'm a Member of the SEIU 721, and I'm supporting 779. Thank you very much. Hello. My name is Lakeisha Gantt. I work for families together of Orange County in the City of Tustin. I'm a medical assistant, and I support SB 779. Thank you. Hi, good afternoon. My name is Valerie Dunboy peoples, and I'm an SEIU 721.

And I'm a phlebotomist from south central LA from Watts Healthcare, and I'm here to support SB 7229. Thank you. Hello, good afternoon. My name is Nabal Bermodez Chan. I am a behavioral health worker, community health worker at lifelong medical care in San Pebble, California, and I urge you to pass SB 779. Thank you, thank you. Alicia Walker from lifelong medical care in Oakland. I'm a clinical coordinator, and I'm here to support SB 779. Thank you.

My name is Jesse Tolka from lifelong medical group, a Member of UHW, and I'm here in support of SB 779. Thank you, thank you. Hello. My name is Perl Martinez. I am a medical assistant at omnifamily Health in Wasco. I'm a proud Member of SCIU, and I support SB 779. Thank you. Minambre es PauLA Carrio, isoi paciente ecomo paciente, ibango De Modesto Cassis. Hi. My name is McDalia Callan.

I'm a patient care coordinator, eligibility specialist in San Pablo, California, lifelong urgent care, SeIU UHW, and I support SB 779. Thank you. My name is Eva Marquez, medical assistant. I work at Tiborciovasquez Health center in Union City, and I support SB 779. Thank you, thank you.

My name is Azure Fedwa Canegradio. I am a consumer relations coordinator with Northeast Valley Health Corporation, and I support SB 779.

Thank you. Hi. My name is Nikki Shortiz, and I'm a perinatal Substance use disorder counselor for Clinica Romero in Boyle Heights, Los Angeles. I'm a Member of the SEIU 721, and I'm speaking in support of SB 779. Thank you. Hi, my name is Lydia Cano for Northeast Valley Health Corporation, San Fernando, here for support SB 779. Thank you. Hello. My name is Fernanda Veronica, northeast Valley Member of SEIU 721, here to support SB 779. Thank you. Hello.

My name is Sonia Orosa. I'm a medical assistant and dental assistant in Benevolence Health Center, Los Angeles, California, and I strongly support SB 779. Thank you. Hello. My name is Terry Evans. I'm a registered dental assistant for the Watts Healthcare Corporation, and, yes, for SB 779. Thank you. Hi, my name is Destiny Parks. I'm a medical assistant at Benevolence Health center in Anaheim, California, and I support SB 779. Thank you. Good afternoon. My name is Sara Medina.

I'm from San Diecro Health, and I support SB 779. Thank you. Good afternoon. My name is Judith Valenzuela. I'm a CNA certified nurse assistant in Saniciro Health center in San Diego, and I'm supported. 779, thank you. Hi, good afternoon. My name is Maria Mercado. I'm from San Diego. I support. This is for Family Health center and SB 779. Thank you. Thank you.

Hello. My name is Gerardo Barbara. I'm a pharmacy technician from San Diego from San Diecedo Health center, and I support SB 779.

Thank you. Thank you. Good afternoon. I am Brandon Dawkins. I am a health worker with the San Francisco Department of Public Health. I am also a Member of SCIU local 1021, and I'm here in support of SB 779.

Thank you. You're wearing a king's hat and you live in San Francisco. Go ahead, please. Good afternoon. Mitch Steiger with the California Labor Federation, also in sport. Thank you.

Good afternoon. My name is Luis Motu. I'm a medical assistant. I work for clinicas El Camino real over in Oxnard, California, and I support SB 779.

Thank you. Hi, my name is Leslie. I'm a health educator at Clinicas El Camino Real in Oxnard, and I'm here to support SB 779. Thank you. Hello. My name is Esmeraldanieto. I'm a medical assistant at Clinica Del Camino Real, and I support SB 779. Thank you very much. Okay, having exhausted the yeses, any opposition to speak on this Bill, please come forward.

Good afternoon, Madam Chair and Members, Dennis Cuevas Romero, representing the California Health Plus Advocates. We represent the community health centers in the State of California. Want to express our appreciation to the Committee and staff for a very thoughtful analysis and for the proposed amendments narrowing the Bill. We're going to take this back to our legislative Committee for review of the amendments. Just want to make a comment in terms of making sure that any additional points really get to the heart of.

I think what our collective hope is, is to improve patient care for all our communities, especially our underserved communities. So really appreciate the author and the sponsor and look forward to continued work.

Thank you.

Madam Chair Member of the Committee, Brandon Marchy with the California Medical Association, an opposing, less amended. Still reviewing the amendments from the Committee, but appreciate the dialogue thus far and look forward to working with the author.

Thank you. Anybody else now? Just wanting to speak. Okay.

Madam Chair Members, Duncan McFetch, on behalf of Ultimed health clinics, we, too, are opposed unless amended. But we thank the author and the sponsors for the amendments. We're reviewing them right now and taking a look at them.

Thank you very much. Anybody else now just come up. Name and affiliation? Seeing none. We'll go to the phone lines. Moderator if there are any calls in the queue.

Well, ladies and gentlemen, if you have opposition or support for this Bill ofSE 779, press 1 and 0 on your telephone keypad and.

It. We'll go to line 42, please. Go ahead.

Good afternoon, Madam Chair. Seth Bramble here, calling on behalf of the California Teachers Association. We are in strong support of Senate Bill 779.

Thank you. Next caller, please.

One moment here. Will we gather their line number? Just queue it up once again. If you have opposition or support for this Bill, press one, then zero on your telephone keypad. Just one more moment here.

Hi there. This is Lily Dorn from the Community Clinic Association of Los Angeles County. I want to echo my colleagues with the California plus health advocates, as well as with ultimed, and just really appreciate the dialogue here today. We, too, are reviewing the amendments, but, really want to appreciate the progress and movement made. Thank you.

Thank you very much. Okay, so I think that will now bring it back to the Committee. Questions? Comments? Senator Menjivar?

Thank you, chair. I do appreciate the intent of this Bill. My only question is the community clinics are here to serve the very same people that we heard say yes for this. I want to make sure, I want to hear if there's any response on the additional burden that would be placed on community clinics that already are struggling to function and provide the services necessary.

Thank you, Senator. I appreciate the question and absolutely agree with your remarks. Right at the heart of this are all of the workers you saw today live in the communities in which they serve proudly so. And we want to make sure those communities getting the care that they deserve in terms of burden on the health centers. That's something that I think we took into consideration as we're walking through the amendment process with the Committee and appreciated the concerns that have expressed around this. The reality is our clinics are doing significant reporting already, and we believe the data points that we are asking for here are consistent with things they are already maintaining for other data reporting they might be doing. So, for example, as relates to some of the quality data and quality conversations we want to bring forward here, there's an opportunity for us to simply be lifting up data. They're already providing some managed care plans for the purposes of reporting publicly in the AUR. And so we're confident that as we kind of move forward in this process and continue to dialogue, we'll continue to find areas like this where, again, we're not looking to have you do complicated new calculations that will take your staff away from patient care or impact you in other ways that might harm your business model, that would, again, take you away from directing your dollars the way in which they should be directed back to the patients. But in fact, our goal here is to make sure, we're only collecting the data we need to collect to have an informed decision here, but how we can move forward future policy and even future funding to uplift these communities and uplift these health centers and the work that's being done by the workforce that was here today. So very much appreciate this comment. I think it's something we're going to continue to take in mind as we work with the author's office and move forward in this journey. Thank you.

Thank you so much. If you could echo to the author that I will be voting this Bill out if he could continue working with the Community Health Clinics on finding a good common ground there. Thank you.

Thank you. And I know you're not the author, but we want to thank the author and the proponents and the opposition. And again, the hardest working staff in the building really digging in on this and trying to get down to the meat of what would actually help and not be so onerous that they had to hire a whole new HR Department to get the data. So with that, would you like to close.

Respectfully ask for an aye vote.

Okay. And this is a do pass, as amended, and rerefer to the Committee on Judiciary. Secretary, please call the roll.

[roll call]

All right, that has six. We'll leave it open for missing members. And now, Senator Wiener is in front of us.

In fact, two. Two excellent bills, Madam Chair.

Two excellent bills, another one of those prior authorizations. And while the first one doesn't say prior authorization, it's kind of prior authority.

I'm sorry, which one do you want me to do first?

Why don't you start with 70? Okay.

Great. Thank you, Madam Chair. First, I want to really thank the committee for working with us, and I'm happy to accept the committee's amendments as outlined in the analysis. Colleagues, for those who were on Health Committee last session, this bill will look familiar because the bill passed this committee, I believe, unanimously last year. Unfortunately, it was held in assembly, approved. So we are back with a narrower version of it.

So this SB 70 strengthens California's prohibition on non medical switching, which is when a health plan forces a patient to switch from a prescribed drug to a different drug for non medical reasons, such as cost. SB 70 will add to that existing prohibition dose level or dosage form. So health plans would not be able to force a switch to a different dosage form or dose level for cost reasons. The bill is personal for me.

As I described when I presented the bill last year, I live with Crohn's Disease, and so I know firsthand what it means when insurance companies sometimes try to push you onto one drug or another, even though your doctor has been clear that a particular drug is the correct drug for you, and that drug could be the difference between leading a healthy and stable life and not, can I have some? She had that guilty look on her face.

Not without a prior authorization.

Senator.

We know that so many Californians live with chronic illness and rely on their physician's judgment in terms of what medication is best for them, what dose, what dosage form, and we need to ensure that they are not disrupted. Especially when a patient is switching insurance coverage, there is significant risk of disruption or forced changes, and we need to avoid that. So SB 70 strengthens patient stability and well being and ensures continuity of care.

I respectfully ask for your aye vote and with me today to testify is Amy Bugwadia, a Crohn's patient and medical student at Stanford, and Ryan Spencer, on behalf of our sponsor, the Crohn's and Colitis Foundation, who will be here for technical questions. Thank you.

Thank you very much. Please.

Madam Chair and Members, thank you so much for having me here today. My name is Amy Bugwadia. I am a medical student at Stanford University School of Medicine, and I've also lived with ulcerative colitis, which is a type of inflammatory bowel disease, or IBD for short, for over 14 years. Now, as a physician in training and as a longtime patient, I am here today to share firsthand the life changing positive impact that SB 70 would have.

When I was diagnosed with IBD at the age of 10, in the midst to fifth grade, I was told that this was a chronic disease with no known cure, meaning that I would have to be managed on medication for the rest of my life because of the complex way that IBD manifests for each and every patient. Each treatment plan is also unique.

And once you find that medication, that finally works, meaning that you no longer have to be running to the restroom in the middle of class, you no longer have to use up all your sick days at work, and you can finally say, yes, I can go to that family gathering instead of being in the hospital. You, of course, want to stay on that medication as long as possible, because the reality is that there are not many classes of medication that can be used to treat IBD.

And so when a patient starts failing on a medication, numerous studies have shown that altering the dose of that same medication can actually allow the patient to achieve remission once more. So instead of having to go through the tumultuous process of switching to a new medication, they can instead just stay on their current one, just at an optimized dose. For example, one of the medications that I take for my IBD is an injection I take at home once every two weeks.

Now, if I were to get sick again, which for me would mean an excruciating amount of pain, an inability to eat, and fatigue, amongst many other symptoms, my physician may decide the best course of action is just to increase my dose to once every week. This would be preferred for so many reasons. My body is already used to the medication.

It's very convenient to fit into my schedule as a medical student taking the injections at home, and this particular medication doesn't cause the severe side effects that other medications have for me in the past. But if my insurance company decides to delay their approval of that increased dose, or if they decide to deny this altogether, then I would be left with no other option to then switch to another medication, which may not even work.

And the problem with this is that once we switch to a different medication, patients can never go back to that original class of medication, which means that whole thing is eliminated for them and is no longer an option. So as a result, patients start to run out of options. But when we're able to keep patients stable on their current medication, we decrease the risk of them having to go to the ER or the urgent care for high cost procedures.

We decrease the likelihood of them having to go on disability, and we decrease the risk of them having to undergo expensive surgical treatments. The reality is that dose escalation is actually a very common and medically safe practice, and insurers ultimately agree that doing so is acceptable. In fact, in 2021 87.5% of IBD patients who appealed their insurance medication denials through California's Department of Managed Healthcare independent medical review process eventually had their request approved.

Which means that in the vast majority of these cases, all we're currently doing is just delaying the care that these patients desperately need in order to survive and thrive. We in California, as Senator Wiener mentioned, have already passed reform for step therapy and for nonmedical switching, which is an incredible step forward for chronic disease patients. But prescription dosage is a huge gap in coverage, which is what SB 70 seeks to close.

I decided to go to medical school because I was inspired by my own IBD journey to work hard to save the lives of children and adults who live with chronic diseases.

But the way that the system is currently set up, no matter how much research I do on optimizing the exact dose of my patient's medication, and no matter how much I believe my patient could benefit from a dose increase on their current medication, there will always be a silent partner, the insurance company, who may delay or deny my patient's right to their evidencebased, dose optimized medication.

So, respectfully, I urge you to support SB 70 to make sure that patients with chronic diseases, including inflammatory bowel disease, have the continuity and quality of care that they deserve. Thank you.

Thank you very much. Did anyone else want to speak than support? Name? Affiliation?

Good afternoon. Sumaya Nahar, on behalf of the California Children's Specialty Care Coalition, in support. Thank you.

Kim Stone, Stone Advocacy on behalf of the California Orthopedic Association, in support.

Madam Chair, members. Tim Madden, representing the California Rheumatology Alliance, in support.

Chris Myers, with the California School Employees Association, in support.

Madam Chair, please don't get tired of my face just yet. Brandon Marchy with the California Medical Association, in support.

Jennifer Snyder, representing the California Life Sciences, in support.

Corey Hashida with the Steinberg Institute, in support.

Rachael Blucher with the California Pharmacists Association, in support.

Le Ondra Clark Harvey, with the California Access Coalition, in support.

Thank you. Okay, having exhausted support, let's turn to opposition.

Good afternoon, Madam Chair, members of the committee. Jed Hampton, with the California Association of Health Plans, representing 43 Knox keen licensed health plans covering over 27 million Californians. Regrettably, we are here today in opposition to SB 70, you know, which would indefinitely limit the health plans or insurers ability to review any changes that are made to an increase in the medication or change in the dosage form of an existing medication or existing prescription for our employees. Apologize for the delay.

I do want to thank the author and the sponsors and the committee staff. We've had several robust and, I think, thoughtful conversations about this bill going back to last year and moving into this year. So we certainly appreciate having those conversations moving forward. As is probably no surprise considering some of the other bills up for discussion today. Health plans rely on several critical utilization management protocols to ensure that patients receive the right care at the right time from the right provider.

These protocols are critically important in promoting safe, effective and affordable care for our plan enrollees. Unfortunately, SB 70 would remove our ability to review clinically appropriate use of prescription drugs if the dosage of the medication is increased or the dosage form is changed, which we believe may lead to several unintended consequences.

We are concerned that stripping plans of our ability to provide this clinical oversight when an increase in potentially adverse reactions from an increase in a drug or a dosage form of a drug could have significant impacts. Safety impacts moving forward, when a health plan chooses to limit the dose of a drug or the dosage form of a drug, it's usually for safety reasons. These safety reasons include consistency with FDA approved labeling and prescribed doses that have been studied or shown to be efficacious.

While we appreciate that the bill attempts to construct a framework to ensure that these changes in dose and dosage form are prescribed safely, we are concerned that this bill does not consider the full clinical compendia recommendations around supported off label uses, that is, increases in off label uses or dosage form changes for off label use of these prescription drugs.

Additionally, we are concerned that taking away our ability to provide clinical oversight could encourage the use of expensive specialty and brand name drugs when a generic or a lower cost brand equivalent is available and clinically appropriate. Lastly, we believe that SB 70 could lead to some dramatically increased costs in the healthcare delivery system.

We think the California Health Benefit review program analysis made several key assumptions in their analysis that may conflict with some of the discussions that we've had with the author's office and the sponsors about the intent of the Bill. In our conversations with both CHBRP and the author's office, we were under the impression that this bill was intended to remove our ability to use utilization review when looking at an increase in dose or change in dosage form from the CHBRP analysis.

They did not take that into consideration and instead assumed that the plans would be able to retain their ability to utilize these protocols, which again, we believe is inconsistent with the conversations that we've had previously. Additionally, our understanding was that the intent of this bill was to freeze the cost sharing provisions indefinitely. And I believe the chipper up analysis made the assumption that those costs would be frozen kind of on a year over year basis and would renew with the plan policy here.

We do understand there are some amendments being discussed that address some of those issues, so we are happy to review those and come back to the committee. But those are just some of the issues that I think we are seeking to get some more alignment on. So overall, we believe that this bill's impact may be much larger than the $27 million in premium increases outlined by the chirp analysis, which we believe will ultimately harm affordability moving forward.

So again, appreciate the conversations that we had with the otter's office and look forward to continuing those conversations moving forward. Thank you.

Thank you very much.

Steffanie Watkins on behalf of the Association of California Life and Health Insurance Companies, we, too, are in opposition to the bill. I will thank. As my colleague mentioned, we've had really great conversations with the committee staff, with the sponsors, and continue those conversations. Unfortunately, for the reasons stated, we are opposed. I think, as we earlier had a conversation in general about prior authorization, there is a concern about restricting a plan's ability on an ongoing basis to review current prescriptions and the potential harm for patients.

So for those reasons, we remain opposed. We look forward to continuing those conversations as the bill moves forward. Thank you.

Yes. Ladies and gentlemen, if you have support or opposition to this Bill at this moment in time, press 1 and 0 on your telephone keypad. We are first going to line 75. Please go ahead.

Thank you very much. Anybody else in opposition? Now is the time to come forward. Name and affiliation? Seeing none, we'll move to the phone lines. Moderator. Do we have anybody in the queue?

On behalf of the California State Association of Psychiatrists in strong support. Thank you.

Thank you. Next caller, please.

We'll now go to line 76. Please go ahead.

Thank you, Madam Chair and members, Alex Khan, on behalf of the California Chronic Care Coalition in support.

Thank you. Next color, please.

Our last comment in queue is line 70. Please go ahead.

Good afternoon, Lauren Finke At the Kennedy Forum and support.

Thank you very much. All right, having exhausted the queue and the room, now is the time to bring it back to the dais. Senators, anybody have a comment, question, motion? Senator Wahab moves the bill. And I'll just say, also thank you to the committee staff for all their hard work on this and the Senator for being amenable to trying to get this just right.

And we do have Javert in the audience if anybody has any questions, although their work was already shaded on, but they're here nevertheless. So with that, Senator, would you like to close?

Thank you. Madam Chair, I respectfully ask for an aye vote.

Thank you very much. And the motion is do pass as amended and re referred to the Committee on appropriation. Secretary, call the roll.

[Roll Call]

Thank you very much. And let me just check with Senator Limon. How's your time?

You can go ahead.

Somebody has a flight.

Yeah.

Give you a chance to get a snack. Senator, that Bill 70, we're going to leave it on call.

Thank you. I appreciate the flexibility. We have someone here that's going to catch a flight, so thank you. Thank you. Chair and members, SB 324 prohibits health plans and insurance policies from requiring prior authorization, something you've never heard of, or other utilization review for any clinically indicated treatment for endometriosis. Endometriosis is referred to as the "miss disease" according by the Center for Reproductive Reproduction Research.

Due to its varied symptoms by patients and inconsistent diagnoses by medical professionals, an estimated one in 10 women in the United States between the ages of 25 and 40 are affected by endometriosis. On average, women in the United States will suffer from endometriosis for 10 years before receiving the proper diagnosis. Currently, under most plans, laparoscopies and other diagnostic studies for endometriosis require prior authorizations before being approved, which can take weeks or months before a procedure or date is set for the patient.

SB 324 will expedite the process for women to receive the proper diagnosis of endometriosis and secure treatment to improve fertility and quality of life. With us today, we have Dr. Sanjay Agarwal, a clinical Professor and Director of fertility services at UC San Diego Health, and Ryan Spencer, a representative ACOG, who will provide testimony in support of SB 324.

Thank you very much. First witness, please. Doctor.

Madam Chair and Members, I do want to make it clear that I'm not representing my employer today, the University of California. Thank you for your work on this bill, which has the potential to make a huge difference to hundreds of thousands of women in California. Endometriosis, as you heard, is a common disease. It steals the peak lives of women of reproductive age. They have trouble with pain, sometimes quite debilitating pain, and can have difficulty with fertility as a consequence of the pain.

They have difficulty with schooling because it can start in adolescence all the way up to menopause. They can have difficulty with schooling, difficulty holding down a job, maintaining relationships because of pain with social functioning, and so many aspects of their life can be suboptimal. SB 324 is, as you heard, geared towards improving access to diagnosis and management of this chronic, debilitating disease. Decreasing barriers to access there are two aspects of endometriosis that need attention most.

One is access to diagnosis and the other is to effective management. I would like to share some facts about endometriosis that will help put this bill in perspective, I hope. Yes, this is a common disease. We heard that there can be a huge delay in diagnosis. ACOG tells us six to 12 years from the onset of pain to a diagnosis of endometriosis. This is an affront on women. Men would not tolerate six to 12 years in pain without a diagnosis. Right.

Endometriosis affects all aspects of a woman's life, her work, her home, her education. Treatment of endometriosis is limited by access so that many women who have a diagnosis of endometriosis still don't receive approved treatments for that disease. Treatments that are based on national medical guidelines, evidence based guidelines. We're not talking about Maverick suggestions of experimental options. We're talking about bread and butter standard options. They don't have access to it.

And as a physician that's seen over 100,000 women and spent 30 years researching endometriosis, my job description is to make a difference to the patient sitting in front of me. And every time I'm not able to do that because of limited access to diagnosis or management, I fail. Of course, this discussion is not about me, it's about the patient. But when I fail the patient, the patient's not happy and doesn't do well either. We have to remember, with endometriosis there is a fertility burden.

And so fertility preservation is an aspect that we should think about as well. With this bill, there will be cost savings with early diagnosis, early management, better management, there'll be fewer ER visits, less opioid addiction, less ruined lives, less unnecessary procedures because people will be diagnosed earlier when the symptoms are more straightforward, rather than later when it can be more complex and there will be less lost productivity. We in California are not the only ones fighting endometriosis.

About four or five years ago, the health minister for Australia apologized to the women of Australia for the poor care of women with endometriosis. I see this bill as California joining the fight against endometriosis. Thank you very much.

Thank you very much. Ryan Spencer.

Thank you, ma'am. Chair. I think the Doctor summarized the issue quite well, as well as the center's opening testimony. So I'll just emphasize, really, regardless of the treatment type, the decision, whether it be surgery or medication, should be left up to the provider and the patient, what is clinically indicated and what is evidence based, and that's what this bill seeks to do. So without any necessary prioritization requirements, they can actually provide the treatment that the patient deserves. And that's why we support the bill. Thank you.

Thank you very much. Okay, anybody else speaking in. Ryan Spencer.

Ryan Spencer on behalf of the American College OBGYN, District 9.

Thank you very much. Ryan Spencer. All right. Other people speaking in support. Come to the mic. Name and affiliation?

Brandon Marchy at the California Medical Association in support.

Nice to see you. Anybody else speaking in support? Okay, opposition. You want to come back? Come on back up.

Madam Chair, members of the committee at Jedd Hampton, the California Association of Health Plans. I think in the interest of time and the robust discussion that we've had around prior authorization today, including the comments from the Senator earlier know, I think we've kind of summarized some of our position around the issue at large. Look forward to working with the Senator's office moving forward. Thank you.

Thank you.

Steffanie Watkins. On behalf of the Association of California Life and Health Insurance Companies, I think we sold someone. We were just going to say ditto. So I'm going to go with that. Very good.

Thank you very much. Anybody else speaking in opposition today? Name and affiliation? All right, seeing none. Go to the phone lines. Moderator.

Anybody in the queue? I'll take that as a no. Now is the time we would bring it back to committee members. Senator Wahab.

Thank you. First, I want to thank the Senator for bringing this bill forward. I really do appreciate it. I also want to thank the first lead witness to all the statements you've made. So what's interesting is I have actually personally suffered from endometriosis. And everything you said is 100% factual. People take time off day after day after day, not knowing exactly what is wrong with them. And the go to of a lot of doctors is pain management. Right.

And they give you an unlimited supply of medicine that just suppresses your pain so you can grit your teeth and go back to work. Right. Or go back to class. It is not fair. There are many women that end up going to the ER regularly, all the scans, and they still don't know. And it is a very invasive procedure to even check if you have endometriosis and to 100% diagnose it.

Some doctors, including my own, said that in order to 100% confirm it, we would have to do invasive surgery just to explore whether or not you have endometriosis. This is 100% not fair. The tools and the procedure as well as the medication, as well as, there's no right way to say that, the way that endometriosis is actually being handled properly in today's sciences. So this bill is one step closer to at least giving some women at least some relief.

And I think that it's incredibly important to highlight women's issues that go beyond the basics. Right. So I really want to thank the Senator for bringing this forward and everybody that is in support of this. So I'll also move this.

Thank you very much, Senator. Anybody else? Okay. And, yeah, I'll say, just as we've all said about prior authorizations that.

Lower the cost here, it increases the cost somewhere else. So I think we're all aware of that and certainly don't want to have policies in place that are an affront to women. Would you like to close?

I respectfully ask for an aye vote.

Thank you very much, secretary. Please call the roll. And that motion is do pass and re-refer to the committee on appropriations.

[Roll Call]

That's 7-0, and we'll leave the roll open for other Members. Thank you very much and have a safe journey back to San Diego, doctor. And again, Committee staff, we're going to ask CHBRP to do an overall analysis on all the prior authorizations over the break, and hopefully that'll give us some more data to be able to really approach this in a thoughtful manner. All right, Senator Wiener, you're back up. SB 238.

Great. Thank you very much, Madam Chair. I'm here today to present SB 238. I want to again thank the Health Committee and yourself and your staff for working with us in the bill. I'm happy to accept the Committee's amendments as listed in the analysis. Colleagues, over the last few years, I think we all know that the mental health challenges facing young people in California and across the country have just exploded. So many of our young people are suffering with mental health challenges.

We know, even before the pandemic, it was a problem. 50% of mental health problems manifest by age 14 and 75% by age 24. And yet we have pretty consistently failed young people in giving access to mental health treatment so we can get in early and help them get back on track. SB 238 will help and ensure that health plans are actually providing mental health coverage that they're required to provide. And we know, because of mental health parity, they are required.

And there's a bad history of health plans refusing to provide mental health coverage. We want to make sure that that coverage happens in a timely manner as well. And specifically, what this bill will do is when a health plan denies coverage for mental health treatment for a young person, anyone under the age of 26, an automatic Independent Medical Review, or IMR, will be triggered. Currently, there's a grievance process it's a multi-step process that can end up taking months.

In addition, we know that everyone is entitled to an Independent Medical Review and IMR. But many people do not even know that they're entitled to an IMR, and they just don't invoke it. And in fact, we know that from the IMRs that are triggered for youth mental health, overwhelmingly, they're English speakers. So it's non-English speakers who are disproportionately not seeking IMRs. And that is a huge equity problem.

We also know that when IMRs are requested relating to youth mental health coverage, overwhelmingly the health plan is overturned and the coverage is granted. So as we heard earlier, this is partly about timing. And when it comes to mental health, we know that time is absolutely our enemy in terms of effective treatment. So this bill, I think, is common sense. It's not expanding what the coverage is. It's a process bill designed to expedite getting these kids and young people the help that they need.

So I respectfully ask for your aye vote. With me today is Dr. Clark Harvey with the California Council of Community Behavioral Health Agencies and Lishaun Francis, who is the Senior Director of Behavioral Health at Children Now.

Thank you. Go ahead, please.

Good afternoon. Dr. Le Ondra Clark Harvey with CBHA. We're a statewide advocacy organization representing mental health and substance use disorder clinics across the state, two thirds of whom provide services to children, youth, and young adults. As a psychologist and as a patient advocate, I've witnessed firsthand the mental health crisis that California's youth are facing and the importance of these services for our kids. Mental illness is killing California's youth. Suicide is the second leading cause of death in youth between 15 and 24 years of age.

Suicide rates among black youth doubled between 2014 and 2020. Prior to the pandemic, California was ranked 48th in the nation when examining children's access to mental health care. The pandemic only exacerbated dire conditions amongst our youth, and many children lost parents, caregivers. They felt isolated from their peers and were exposed to unstable home environments. Youth with poor mental health often struggle with school grades, absenteeism, acting out behavior, and substance abuse.

This can increase their risk of sexually transmitted infections, emergency room visits, neurological impairments, developmental delays, and the list goes on. So what has long been a crisis has now morphed into a full blown emergency. Yet many health plans continue to deny care at an alarming rate. When a child comes to our providers, they often are struggling with chronic anxiety, ADHD that's unmanageable, depressive episodes, or bipolar disorder.

They work to understand their illness and prescribe culturally congruent care that takes into consideration their family history and their very unique needs. So it is extremely frustrating when their plan denies such care, often because of medical necessity disputes. So navigating our healthcare system to access care is already challenging enough for youth and their families. And for the few that have the time and the resources to persist, they tend to encounter barriers when attempting to file a grievance or appeal a denial through the independent medical review process. SB 238 would put the power back in the hands of providers and clients to decide what kind of care is right for them without placing the burden on families to fight the system. Thank you.

Thank you very much. Next person, please.

Thank you, Madam Chair and Members. My name is Lishaun Francis, and I'm with Children Now, and we are proud sponsors of Senate Bill 238. We hope the case stories that we provided you today gave you a sense of how the IMR process can be used to settle concerns that are important to families regarding their children's mental health. Those cases highlight when the IMR process was utilized and a positive outcome was declared.

Our bill is about what happens when families don't utilize the process because they don't know how, or they don't speak English, or they are simply overwhelmed parents who are trying to keep their head above water. That is why I wanted to take the time to share one story from one of our provider friends who was kind enough to send me a very detailed email about their experience.

They wrote: Recently, we referred a 10 year old boy with large commercial insurance coverage to residential treatment due to difficulties regulating mood and increased physical aggression at home. He struggled with a history of being bullied at school and had previously engaged in self harm twice by cutting himself with a knife. After two weeks of treatment, his insurance coverage for the residential treatment program was denied. We requested a peer to peer review, at which time another week of treatment was approved.

After that week was complete, another denial was issued. During these denials, he was behaving aggressively with peers and staff, and we were actively changing his medications, hoping for a different outcome. The family agreed to pay out of pocket, hoping they would be able to convince their school district to cover some of the costs through their son's IEP process. With this case, no appeal was filed because the family was focused on obtaining funding through the school district.

The provider noted that if this had been referred automatically to the IMR process, a more thorough review of the medical necessity criteria may have yielded a different result. While in this case we can't know if this would have been approved, one thing that we consistently see is that families who are covered with commercial insurance through their jobs are often relying on public funds to pay for things that, theoretically, their health insurance should cover.

You've heard a lot today about how patients struggle to get the care they need from health plans. SB 238 is actually pretty simple. It eliminates the requirement for a parent or caregiver to pick up the phone and fight with their plan. For those reasons, we really hope that you'll support SB 238.

Thank you very much. Other people speaking in support, now is the time to come forward. Just name an affiliation, please.

Nora Lynn with Children Now on behalf of the California Psychological Association, in support.

Katie Van Deynze with Health Access California in strong support. Thank you.

Madam Chair and Members. Bryce Docherty on behalf of the American Academy of Pediatrics California, in support.

Madam Chair and Members. Tim Madden representing the California Chapter of the American College of Emergency Physicians, in support.

Thank you.

Thank you, Madam Chair and Members. Amer Rashid with the County Behavioral Health Directors Association of California and Support. Thank you.

Thank you.

Thank you. Melissa Cortez on behalf of Autism Speaks and the Center for Autism and Related Disorders in support.

Thank you.

Le Ondra Clark Harvey on behalf of the California Access Coalition, in support.

Thank you.

All right, now would be the time for opposition. Come back on up.

I would like to echo my colleagues' comments about getting sick of seeing my face today. But, once again, Jedd Hampton with the California Association of Health Plans, regrettably, here in opposition to SB 238. First and foremost, do want to thank the author's office and the sponsors. Once again, we appreciate your open door policy, Senator, and working with the sponsors of the bill.

We've had some very good conversations regarding this bill moving forward, and we certainly share the goal and the aim of what this bill is trying to accomplish, and that we are serving the mental health and substance use needs of our young people in the state. So we're fully committed to that, and we certainly appreciate that intent.

Regrettably, however, this bill is ignoring some key considerations, from our vantage point, in the claims determination process that could ultimately lead to, actually, delays in care, which is what we're primarily concerned about. Our primary concern is that the bill completely removes the health plans' existing secondary review process after a grievance has been filed. That often allows the plans to resolve initial denials and modifications quickly.

Typically, when a plan issues a denial or a modification, oftentimes that's generally because there's missing clinical information, chart documentation, or there's generally a miscommunication between the plan and the provider. Oftentimes, during this secondary review process, once a grievance has been filed, we can oftentimes go back to that provider, that individual, clear up the miscommunication, get the documentation charts that we need, and then proceed with overturning that claim and moving forward and getting that individual the care that they need quickly.

However, this bill would automatically submit those claims to the IMR process, and once those claims have been submitted to IMR, that's obviously administered by a third party, health plans have no ability then to resolve those grievances and those complaints quickly. And therefore, we're essentially taken out of the process by this bill, and we were concerned that that actually is going to lead to delays in care moving forward.

So automatically triggering the IMR process without the ability of health plans to internally review the initial request, again, once again could lead to delays in care and force them into a process that doesn't necessarily lead to a more timely outcome, which we think is certainly important. It's important to note that health plans are statutorily required to resolve grievances under three days for excited appeals and 30 days for standard appeals.

Generally, these disputes are resolved much more quickly than the statutory timelines require, which is oftentimes completed more quickly than if the case were actually sent to IMR. We're also concerned about the potential impact that SB 238 might have on the integrity of the current IMR system. Automatically referring denials or modifications to the IMR process, regardless of merit, will certainly lead to a massive influx in cases, thereby compromising the ability of the current system to work efficiently and effectively in resolving these cases in a timely manner.

We certainly agree, again, with the intent of this bill and with the author and the sponsors, that individuals suffering with mental health and substance use disorder should receive the medically necessary care that they need. But we believe, unfortunately, that SB 238 has some unintended consequences that actually might build more costs into the healthcare delivery system. So, once again, for these reasons, we are opposed to SB 238, but look forward to continuing those conversations with the author and the sponsors.

Thank you. Steffanie.

Steffanie Watkins on behalf of the Association of California Life and Health Insurance Companies. Regrettably, we are too opposed. We've had really great conversations with the author and sponsor. I think there's been a little bit of an education process about the initial approval, how that works, and the secondary level of grievances and how it functions and moves to IMR.

I think our concern is, especially on the RX side, which is on the pharmacy side, we have 24/72 hours to approve or deny those, or they're automatically approved. So one of the conversations that we've had is, and I know it's not the intent, is to move things that are simply missing paperwork or lab work, kind of simple fixes, to move to approval, that you would be moving those to IMR. But under the current structure of the bill, that's exactly what would happen.

And most likely what you would see is those being moved directly to IMR and then potentially canceled later by the physician. Our concern is, as those move into the IMR process, so does those IMR reviewers start to do their work, and does that then create future delays for other things that really do or should go through IMR? So I think we're hopeful that we can continue those conversations.

We do see the grievance process as a functioning assistance to move things quickly and move them to approval, especially for those instances where we're missing paperwork or approvals or lab work. So for those reasons, we remain opposed. We look forward to continuing those conversations. Thank you.

Thank you very much. Anybody else wishing to speak in opposition of this bill? Now's the time. Name and affiliation. Seeing none. We'll go to the phone lines. Moderator, anybody in the queue for this bill?

Gentlemen, if you would like to comment in opposition or support, you may press 1 and 0. We'll go to line 80. Please, go ahead. Line 80, your line is open. We'll move on to line 41. Please, go ahead. Line 41, your line is open. Move on to line 77. Sorry, go ahead. Line 41. We'll move on to line 77. Please, go ahead.

Andrea Rivera on behalf of the California Pan-Ethnic Health Network in support. Thanks.

Thank you. Next caller, please.

We'll go on to line 78. Please, go ahead.

Priscilla Quiroz on behalf of the California Academy of Child and Adolescent Psychiatry and the California State Association of Psychiatrists in support. Thank you.

Thank you. Next caller, please.

Next, we'll go to line 46. Please, go ahead.

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

Thank you. Next caller, please.

Next, we'll go to line 81. Please, go ahead.

Hello, this is Kevan Insko, Friends Committee on Legislation of California in strong support. Thank you.

Thank you. Next caller, please.

Next, we'll go to line 70. Please, go ahead.

Hi, Lauren Finke with the Kennedy Forum in a support if amended position. We're appreciative of the number of suggested amendments the author and sponsors have agreed to take in this Committee, and we believe this moves the bill closer to its intent. However, we still have remaining concerns that we will continue to work with the authors and sponsors on to ensure consumers are protected throughout the IMR process. Thank you.

Thank you very much. Next caller, please.

Next, we'll go to line 47. Please, go ahead.

Hi, this is Rachel Velcoff Hults on behalf of the National Center for Youth Law in support of the bill. Thank you.

Thank you. Next caller, please.

Next, we'll go to line 72. Please, go ahead.

Hey, this is Lily Kotansky with the National Association of Social Workers, California Chapter, and we are in support of this bill.

Thank you. Next caller, please.

Next, we'll go to line 53. Please, go ahead.

Madam Chair, Members of the Committee. Randall Hagar on behalf of the Psychiatric Physicians Alliance of California, in strong support.

Thank you. Next caller, please

Next, we'll go to line 80. Please, go ahead.

Hello, Madam Chair and Members. Janice O'Malley with the American Federation of State, County, and Municipal Employees, in support.

Thank you. Next caller, please.

Next, we'll go to line 86. Please, go ahead.

Madam Chair and Members. John Wenger on behalf of America's Health Insurance Plans in opposition.

Thank you. Next caller, please.

There are no more in queue. Back to you, Madam Chair.

Okay, thank you very much. This time we'll bring it back to the Committee. Senator Gonzalez.

I just want to say thank you to Senator Wiener for bringing this forward and to your sponsors. I think it's an incredible bill. I'd love to be added as a co-author. Having a 16 year old stepson and his many friends who've had a lot of instances where we need the help and have been denied. I think this is another opportunity for us to be able to take care of these youth. So with that, I thank you very much. Thank you, Senator, and happy to move the bill when appropriate.

Thank you. We'd love to have you on the bill.

That bill's been moved by Senator Gonzalez. Anybody else? Okay, would you like to close?

No, I just want to thank everyone. This has been an amazing coalition behind this bill, and I think this will really help get these kids the help they need. And I respectfully ask for an aye vote.

Thank you very much. And the motion is do pass as amended and rereferred to the Committee on Appropriations. Secretary, please call the roll.

[Roll Call]

Eight has eight votes, and we'll leave it open for Members to add on. Senator Hurtado, representing SB 472. And we thank you in advance for accepting the proposed amendments.

Good afternoon, chair Members. Of course, you're welcome. I'm happy to accept the amendments. Today, I'm here to present SB 472, which creates the Naloxone School Accountability act. First, I would once again start by thanking the Committee consultant Reyes Diaz, for working with me and my office on amendments, and I'll be accepting them, which are found on page three of the analysis. As we know, there's an opioid crisis here in the US and California.

Of course, of the nearly 3000 Californians that died from opioid overdose in 2019404 were between 15 and 24 years old. The Naloxone School Accountability act will allow us to have a better understanding of the opioid crisis in our youth, while also allowing schools to share resources to parents from the State Department of Public Health about naloxone this Bill is one of many ongoing efforts in the opioid crisis in the state.

SB 472 will require each school district County Office of Education to have two doses of naloxone on its school campus and to report to the State Department of Education and the State Department of Healthcare Services on or before July 312024 and annually thereafter about certain information regarding opioid antagonist. Unfortunately, my witness could not make it here today. But thank you for your time and I respectfully ask for an aye vote.

Thank you. Anybody here speaking in support? All right, anybody speaking in opposition? All right, going to go to our callers. Anybody in the queue?

Ladies and gentlemen, if you wish to speak in opposition, support, you may press 1 and 0 at this time. We have no one in queue.

Okay, thank you very much. At this time, we can bring it back to the Committee. It's been moved by multiple people. Pick one. Secretary, again, we thank you for. This is a good Bill. We're going to have naloxone on campus. We're going to have trained people to administer it, and we're going to have reporting done about the outcomes. So I think that's a great Bill and I'd like to even be added as a co author and secretary. Please call the role. The motion is do pass as amended and re refer to the Committee on Appropriations. And we thank the Senator for getting us back on time.

[Roll call].

Has eight votes. We'll leave it open for absent Members. And I already see our next Senator up. Ready to go. Senator Menjivar, let's talk about sexual health contraceptives.

Yes. Thank you so much. Good afternoon. First of all, happy STI awareness week. So I think it's just so appropriate to bring up this bill. We are in a crisis right now, an STI crisis. And SB 541 is a step forward to help address this crisis. SB 541 seeks to address this epidemic among California as a whole. And it's looking to do four specific things.

First, expand the access to condoms in our public schools to be located in two different locations for our children to be able to utilize them to bar schools serving 7th through twelveth grade from prohibiting distribution of condoms in the context of educational and public health programs and initiatives. Three, it's going to prohibit pharmacies and retailers from asking proof of age.

Right now, there is no law requiring someone who is looking to purchase contraceptions to ask for an ID. But it's happening, and it's not deterring our youth from engaging into sexual activity. It's in fact, having them have sexual activity, intercourse, without protection. My bill is also looking to ensure that there's no wrong door for the HPV vaccine. Currently, our family packs are unable to serve minors who are looking to get the vaccine.

And I'm looking to ensure that individuals 12 to 18 can go to their local family pact and obtain the HPV vaccine. HPV right now is the leading Sci and most common STI in the nation. We are seeing right now that one in five people nationwide have contacted STI. Here in California, over 50% of that are people between the ages of 15 and 24 years old. These are the youth that we're talking about.

I understand that parents will continue to have conversations with our youth, but we cannot be with them 24/7. And should a youth make that personal decision, I want to make sure they have the necessary resources to stay safe and healthy. The common barriers that incur right now is some that I've already mentioned. We have individuals at stores that are asking for ID. They're asking for proof of age that put these things behind closed barriers. And again, it's not deterring our youth.

It's just increasing our rates of STI. Providing condoms in our schools ensures that our youth stays safe and healthy. I'm proud that this bill is being youth led. It's the youth that brought this forward and are seeing that they find that their schools have a responsibility to provide this to them. There was a study done in late last year, in December 2022, that showed that 55% of teens agreed that they would use the condoms if it was easier to obtain.

60% agreed that schools should make them more available. Lastly, like I mentioned, the last part that this bill would do would be focusing on the HPV vaccine. Currently, not every single family pact has the vaccines for children program, which is allowing this vaccine to be distributed. So I want to make sure we're closing that gap. Here with me today in support of this bill are two of the co sponsors, Sylvia Castillo with Essential Access Health, and Kim Robinson with Black Women for Wellness.

Thank you. Thank you. Please go ahead.

Good afternoon, Chair and committee members, and again, happy STI Awareness week. My name is Sylvia Castillo, and I'm the director of government affairs at Essential Access Health. We advance health equity and promote quality sexual and reproductive health care for all. We work in close partnership with the state, county health departments, community providers, and other stakeholders to increase access to reproductive health care, including STI prevention, testing and treatment. We're proud co sponsors of this bill, along with our other partners.

As the Senator mentioned, we are living through an STI epidemic here in California and across the nation, which has reached crisis levels. Just yesterday, the CDC released the most recent data on nationwide STI rates, which is from 2021, and the picture it paints is not very pretty. Across the board, STI rates continued to rise. There were 1.6 million cases of chlamydia reported in 2021, and gonorrhea rates increased 118% over the last 10 years.

Syphilis cases saw the steepest rise, with a 28.6 increase from 2020 to 2021. Since most STIs are asymptomatic, they are often left undetected and can pose serious, life threatening health problems later in life. In 2018, the CDC estimated that STIs cost the US healthcare system approximately $16 billion in direct lifetime medical costs. About 36% of that cost accounted for care provided to youth ages 15 through 24. This is why youth need and deserve equitable access to condoms and the HPV vaccine.

Condoms are an effective tool to reduce STI transmission, and it's one part of a multipronged public health strategy to address stis. However, condom use among sexually active teens has declined over the last decade. Many teens face significant barriers to accessing condoms. This includes stigma, judgmental providers and retail staff, limited transportation and cost, among others. This is why some schools have already been distributing condoms. Now we need to make this equitable across all public high schools in our state.

The HPV vaccine is another vital health tool to reduce incidences of hpv related cancers. While 80% of California teens received the first of the three doses of the vaccine in 2020, the vast majority do not complete the full vaccination series, leaving them without maximum protection. And while we were thrilled when the California Family Pack Program began covering the vaccine, we were dismayed that the benefit was only extended to those who were 19 and older.

Because the issue is that while most minors can get this vaccine through the BFC program, not all 2000 plus FPAP providers are enrolled from that program. And they have shared with us that they have had to turn away some teens because there was no way to give it to them without coverage. So to promote health equity and continuity of care, we need to ensure there is no wrong door for teens seeking the HPV vaccine. For these reasons, we urge you to vote yes today. Thank you.

Thank you very much. Next witness, please.

Good afternoon and thank you, Madam Chair and committee members. My name is Kim Robinson and I'm the community liaison with Black Women for Wellness and Black Women for Wellness Action Project. We are a statewide reproductive justice community based organization committed to improving the overall health status and well being of black women and girls. I'm reading this testimony on behalf of Lionel Schuler, who serves as the program lead for Black Women for Wellness.

Get Smart Before You Get Sexy Program, our comprehensive sex-ed program dedicated to eliminating health disparities that persist in our community. Black Women for Wellness Action Project is proud to co sponsor SB 541, the Youth Health Equity and Safety Act because it is a huge step in eliminating health disparities and it removes barriers that limit youth access to critical resources.

This Bill will advance health equity, improve health outcomes, and support safer sex behaviors among teens by requiring that California public and charter high schools make internal and external condoms readily available to students, prohibiting retailers from asking for ID for condom purchases, and increasing access to the HPV vaccine. As program lead for Get Smart, a large portion of my work is to train peer educators from high schools across LA County to lead comprehensive sex ed workshops in schools and in the community.

We educate around 1500 to 3000 youth and young adults between the ages of 12 and 30 years old on sexual health topics like consent, body image, sexually transmitted infections, birth control, gender identity and expression, to name a few. Last week, after hosting an event on health advocacy, one of our peer educators that attend Kings Drew Medical Magnet High School thanked me for doing this work. She said that before joining Get Smart, she had not received any sex-ed in school and considered herself to be clueless.

So when her boyfriend wanted to take things further, neither of them knew where to get condoms from or who to ask. She said she supports bills like SB 541 because she recalls the fear and stigma she felt after experiencing a pregnancy scare and not feeling like she had anyone to talk to or where she could go for help.

She wished her school provided sex education and made sure that condoms were accessible so that she and her partner would be equipped to make better decisions for themselves. At Get Smart, our mission is to ensure youth have the knowledge and tools to make the most informed decisions about their health. The advantages of mobilizing resources is why I implore you all to vote yes on SB 541. We are fighting around the clock to ensure we are making progress in addressing the STD epidemics.

Thank you very much.

Thank you.

Anybody else speaking in support? Just name an affiliation at this point.

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

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

Ruth Dawson with ACLU California Action in support. Thank you.

Kathy Mossburg, representing the San Francisco AIDS Foundation as well as the End the Epidemics Coalition in support.

Ryan Spencer with the American College of OBGYN's, District Nine in support.

Thank you. Anybody here today to speak in opposition? There's no lead. Okay? Anybody just want to get up and say they oppose? Okay, let's go to the phone lines. Is there anybody in the queue?

If you have any opposition or support at the moment, press one, then zero on your telephone keypad. We will go to line number 42. Please go ahead.

Good afternoon, Madam Chair. Seth Bramble calling on behalf of the California Teachers Association. We are in support.

Thank you very much. Next caller, please.

Next caller is line number 91. Please go ahead.

On behalf of the California Faculty Association in support.

Thank you. Next caller, please.

Our next caller is from line number 83. Please go ahead.

Ria with Generation Up and senior at Riverside STEM High School calling in strong support.

Thank you very much. Next caller, please.

Our next caller is from line number 90. Please go ahead.

Hi, my name is Fiona, and I'm a senior at Northwood High School in Irvine Unified and also with Dennis and strong support.

Thank you very much. Next caller, please.

Our next caller is from line number 87. Please go ahead. And your line is open. Please unmute yourself if you muted. We'll go to our last caller, which is line number 88. Please go ahead.

Hi, my name is Kimberly Wu. I'm currently a senior at UC Berkeley, also with Gen Up, and we are in strong support of this bill. Thank you.

Thank you very much. Okay.

Here's two other people have queued up, so one moment. It looks like we will go to line number 92. Please go ahead.

This is Greg Burt from the California Family Council in opposition.

Thank you. Next caller, please.

And the last caller that is queued up is line number 93. Please go ahead.

Hi, my name is Jennifer Tram. I pronouns are she/her. I'm a student at UC Berkeley, and I am supportive of this bill.

Thank you very much. Okay, having.

One other person just queued up. One moment. Okay, it looks like we'll be going through the line number of 85. Please go ahead.

Student at Poly High School, and I'm in support of SB 541.

Thank you. Is that it, moderator?

From what I can tell, that was the last person.

All right, let's cut it off, then. Thank you very much. Now's the time to bring it back to the committee. Questions, comments, move the bill by Senator Roth.

Don't give it to her.

Senator Wahab, the secretary made the decision.

Senator Wahab.

Okay. Ears closer over there. Okay? Yeah. Thank you for bringing this bill forward, and happy STD week to you, too. Would you like to close?

I know this isn't a sexy topic. Sometimes it can be uncomfortable, but this is a crisis and it's a tool to combat this crisis. So I respectfully ask for your aye vote.

Thank you very much, secretary. Please call the roll. And the motion is to pass and re-refer to the committee on appropriations.

[Roll Call]

Okay, we'll leave the bill on call. I'm now the new chair for just one more Bill. Hello, Senator Nguyen, you may present.

Thank you, Madam Chair. I'm here today to present SB 625, which seeks to bring about more transparency to the process surrounding the collection, storage, and use of newborn genetic data that is currently collected and stored as part of California's Newborn Screening Program. I would like to thank the bill sponsor, California Health Coalition advocacy, and the Health Committee staff for working with my staff on the amendments, and I'm agreeing to take those amendments as well.

SB 625 is the first and foremost a bill about individual rights, the rights to privacy, and ensuring informed consent surrounding the use of very personal and sensitive information. The Newborn Screening Program has been a fantastic and nationally recognized program that we have here in California and has certainly helped with the research and study of many different genetic diseases or conditions.

There is no denying that there has been a great net benefit to the things scientists and researchers have been able to learn about through samples provided by this program. However, as a parent of two California-born children, I need to understand what has been done with this information and the information taken from the blood spots collected at the time of birth. I shall be honest, before I was even doing this bill, I didn't know that we were doing this, so I had no clue.

I remember the cards. If you remember when you gave birth, there's this card that's given that has the baby's fingerprint and footprint and then a dab of blood. That's the collection that's been collected. And that information, though, gets to the state data. And I didn't know that was not informed to me. I thought that was just a process that every baby had to go through.

California parents are not being properly informed of their rights regarding the collection, storage, and use of these blood samples or other genetic materials collected by the state for the newborn screening program. As a mom who remembers most everything about my pregnancy, again, I cannot recall signing or acknowledging any release form or consent form informing about the blood collection and storage and use of the collected samples from my children.

After speaking with many parents in the community and around my district, I've listened to the same stories from parents. Most of those parents that I spoke to will have no problem with the samples or the collection of their children's samples, but I think we should be informed and being allowed to give consent.

There's no denying the importance of the work by the researchers who have access to these samples, but Californians should be properly informed and have a choice in how their genetic data and information is being used in access. Parents and guardians should be fully informed about the process of collecting, analyzing, and storing these genetic information collected from newborn infants. With me today is Stephen O'Connor, Staff Attorney from the nonprofit National Health Freedom Action, to share his testimony and expertise on this subject. Thank you.

Thank you. Good afternoon, Chair and committee members. As noted, my name is Stephen O'Connor. I'm a Staff Attorney with National Health Freedom Action, and we are a 501c4 that helps to promote health right, medical rights, and health freedom around the United States. We help state-level groups in reviewing, drafting, and promoting bills, such as the California Health Coalition advocacy. We've worked with them on this bill, and we do support it.

Now, first off, the mandatory genetic screening is an important public health matter, and this bill does support that process. I want to note that the genetic data in newborn blood samples is highly distinguishable and cannot be truly de-identified because the samples are stored indefinitely, and third parties are given access. Consumers are concerned about genetic privacy. At present, parents are poorly informed, if at all, about the storage and medical research of the newborn samples and are not able to withhold consent.

By comparison, California already requires consent for pregnancy blood samples to be used for research, and this bill simply applies a similar standard to newborn screening samples. Newborns and parents should have a clear and unambiguous right to privacy and full knowledge of the future impact of medical procedures. The new subsections I and K of H and S 125000 codify the knowledge and consent that parents deserve.

The new section 125003A5 provides that the written brochure provided to parents give notice of the right to withhold consent, and the new section 125005B1 ensures that parents are informed of their rights at least four weeks prior to the estimated delivery. We are in a world in which scientific progress will bring challenges for civil liberties, especially our rights to privacy. For example, convicted felons in California must provide a DNA sample for future use.

In that case, there's a reasonable nexus between the DNA requirement and the underlying conviction. Under current law, newborn babies are effectively being treated as suspects. To the degree that police can attempt to access the biobank data even many years in the future, the benefit from real-time testing for genetic disorders is clear, and this Bill in no way hinders that benefit.

And as a note side note, the proposed bill says that if a parent is unable to complete the form, the sample will be taken and may be used for research. That's 125004 e, the new section. But the storage of samples for medical research is a completely different use, one that's in the public good before a parent trades some of their newborn's privacy and what is initially done for a personal benefit.

Before they trade that for a public benefit, they should have a clear notification and a clear right to opt-out. Likewise, potential use by law enforcement is another public benefit. And since the research is secondary to the care of the newborn and any law enforcement access is then secondary to the storage for medical research, it's frankly too far removed to be allowed. This issue is cured by the new subsection J of 125000 Health and Safety Code, which precludes use of the biobank by law enforcement.

In a July 26. 2022 piece from the article from the ACLU's Technology fellow Crystal Grant, they note that police access to these biobanks endangers public trust in the process and, quote, threatens all American's right to genetic privacy. And just to finish up quickly, folks, a couple of notes on the legislative analysis in this case on page seven, paragraph eight: their main complaint seems to be that it's changing it to an opt-in.

But my understanding is that amendments that are being accepted will create this into an opt-out. So that problem is solved. The second paragraph on page six is quoted that it's not used to create a database, yet law enforcement can get access with a search warrant. So that's incorrect. At page seven, paragraph eight, the opposition indicates that this would not provide any new rights, but it does by precluding law enforcement access.

And finally, at page eight, paragraph nine, they note that the biobank has 30 years of stored data without express consent. That's part of the problem, and this bill will fix that.

You're approaching your six minutes, sir.

Thank you. That's all I have to say. I want to say thank you so much for your attention and ask you to vote aye on this measure.

Thank you very much. Okay, so no more witnesses, but now if anyone just wants to speak in support of the bill, now's the time for you to come up and do that.

Quintin Levesque on behalf of California Health Coalition, advocacy proud sponsor of the bill, and American Nurse Association in support.

Thank you very much. Anybody speaking in opposition to the bill today, please come forward.

Good afternoon. Chair and committee members: Vanessa Gonzalez with the California Hospital Association with an opposed position on SB 625. California's newborn screening program is extremely important and tests newborn babies for about 70 rare and seriously disabling diseases. If identified early after birth, many of these conditions can be treated before they cause serious health problems. Only a small spot of blood is taken from the baby's heel for testing. After testing, the small spot of blood is securely stored by CDPH and occasionally used for important research.

It is important to emphasize that parents currently have the ability to opt out of the testing, storage, and research components of this program. All parents are already given information by their doctor about how they can opt out. Unfortunately, the agreed-upon amendments do not address concerns as parents would now be required to complete a consent form at least four weeks before their due date.

The consent form would have four different signature lines for the parent to acknowledge receipt of the information or opt out of various components of the program. The concern with this form is that many moms will inadvertently not fill it out, and the bill is unclear whether the baby can be tested if this form is not filled out.

Because parents already have the ability to opt out of the newborn screening program and newborn babies may inadvertently not get tested for serious conditions, we respectfully request your no vote on SB 625. Thank you.

Well, ladies and gentlemen, if you have opposition or support at this moment, press one, then zero on your telephone keypad. We have one person that's queued up. One moment, one.

Thank you. Next witness. Okay, seeing none, anybody else just wants to speak? Do a me too. Okay, seeing none, we'll go to the phone lines. Moderator?

All right. They're not quick.

Okay, just one moment. Here's. Like a line 94. Please go ahead.

Madam Chair and members, Amy Blumberg with the California Children's Hospital Association in opposition, and I align my confidence with the California Hospital Association.

Thank you very much. Is there another caller?

We have no further callers.

Okay, thank you very much. Now it's time to bring it back to the committee. Questions? Comments? Senator Wahab. Menjivar. Menjivar. I'm Gonzalez. You're Wahab.

Blonde.

It's been a long day.

I just want a clarification. The witness in opposition mentioned that you can currently opt-out. Then what would be the purpose?

So you can currently opt out, but no one informs the parents about it at all. So when you go in, we're not informed. I don't remember getting anything at all when I gave birth to both of my boys, I didn't even know this collection was even happening. If I was informed. When you're pregnant, you get lots of forms, and there's lots of forms for opt-out as well. So it's not just one form. And so most of us parents would go through all those forms. But if you're just told of something I don't remember. Even if you can opt out today, you're not informed about it at all.

Did you want to ask the CHA.

Go ahead. Yeah. So the current requirement is at least four months prior to birth. I'm sorry. Four weeks prior to birth, the pregnant mom's physician is required to give them a pamphlet that's been created by CDPH and gives them all the information about the newborn screening program and also has the information on how they can opt out of the test, as well as the storage and research. And every mom receives that pamphlet.

For your bill, Senator, if a parent opts out, does it require them to give a reason? It's just opt-out?

It's just a form just to opt-out. And it also allows an individual, once they reach 18, to also ask for their information back as well, because right now we have no access to knowing if it's still there or not and not even knowing where that data is going.

And that was one of the amendments we took. The initial bill was people had to sign to opt in. And so we just said, no, they have to sign to opt out.

Makes it easier. Senator Wahab, let's call on Rubio.

Thank you. So when the hospitals take this sample and they're in particular, like, let's say they have to keep it in some type of database, correct? Right? No?

There's that cardboard card that I mentioned.

Yeah, but a lot of blood, and it goes on a card. There's no DNA database. The card does not have the baby's name. It has an ID number. And then there is a computer that is not hooked up to the Internet that matches the number on the card with the baby's name and birth date in case some follow-up has to be done.

Okay, but no DNA information of any kind, correct?

No, just a.

What are we asking back? So when the kid turns 18, they.