Assembly Standing Committee on Health

If you represent one, all testimony comments are limited to the Bill at hand. We do have a proposed consent calendar today. That calendar consists of the following items. Item number two, SB 694, by Senator Eggman. Item number four, SB 641 by Senator Roth. Item number five, SB 19 by Senator Seyarto. So that will leave us with amendments. Excuse me. Thank you. So that will leave us with four bills, and the first Bill today is Senator Caballero, SB 621. We are operating as a Subcommitee, a small Subcommitee, until we have more people, and it's growing. That's good. So whenever you're ready, Senator.

Thank you very much, Mr. Chair and Members, I'm pleased to present SB 621. Californians, especially rural residents, are confronted by health access challenges that I know are very familiar to you, Mr. Chair, such as hospital closures, limited treatment for access, lack of transportation, and high prescription drug prices.

This Bill will target a crucial area of healthcare accessibility to lower the price of prescription drugs, which have high prices, and due in part to the lack of competition that branded drugs receive from lower priced but equally effective options. Biosimilars are drugs that are rigorously tested and approved by the FDA as having, quote, no clinically meaningful difference from a brand name drug in terms of safety, purity and potency. According to the FDA, biosimilars are as safe and as effective as the original biologic.

Both are rigorously and thoroughly evaluated by the FDA before approval. And before that approval, FDA experts must conclude that it's highly similar to, and has no clinically meaningful difference from the original biologic. The introduction of biosimilars frequently leads to increased access for patients, driven by the lower cost. Since biosimilars have been introduced in the US, they have saved over $13 billion and are expected to generate over $180,000,000,000 in savings over the next five years.

Despite biosimilar's widespread adoption in Europe, barriers to their adoption remain in the United States due to the power of the prescription drug companies, which have used the legal system to block the widespread adoption. This has resulted in higher healthcare premiums and tens of thousands of dollars in out of pocket costs for the patients with chronic conditions. This Bill provides health plans with the tools to access the lower cost biosimilar without the need to try the equivalent brand treatment first.

It extends the relevant patient protections to the usage of biosimilars, such as the ability of the provider to request that the original brand treatment to be utilized. In other words, it doesn't take that off the table. A prescriber in California will have to approve the use of biosimilars prior to it being administered to a patient.

I'm proud to say that the patient groups like the International foundation for Autoimmune and Inflammatory Arthritis and the AIDS Healthcare foundation, and groups from rural California, like the African American Farmers of California and the NISI Farmers League, support the Bill because we are working to lower the price of prescription drugs and reduce healthcare premiums without delay to ensure patients with chronic conditions have the care they need. With me today to testify is Brett Michelin from the Association for Accessible Medicines.

Good afternoon, Mr. Chair and Members Brett Michelin with the Association for Accessible Medicines. AAM represents the generic and biosimilar manufacturers and are pleased to sponsor this Bill and thank the Senator for carrying it. Our intent behind the Bill is really quite simple, and that is to increase access and reduce costs, some specific reductions of costs through the use of biosimilars for particular drugs.

The Senator has already mentioned some of just the scope of biosimilar savings, but we've already seen with the first biosimilar insulin come to markets being offered at a 65% reduction from the reference drug. There was recently what will be the second Humira biosimilar, and it is going to be offered at an 85% reduction from the referenced brand drug. So the data is very clear. There is very significant cost savings.

The data has also shown that there is no increased risk from using biosimilars from the reference product or really for any interchangeable biosimilars. And I'm happy to answer any questions. I know there's often questions on really, what are the differences between the reference product biosimilar and an interchangeable biosimilar. But I'll wait for any questions, if there are any, for that.

Okay, thank you. Do you have other witnesses in support? Are there others in support in the audience? Just your name, organization, if you represent one.

Good afternoon, Mr. Chair and Members Andrest Ramirez, on behalf of the City of Soledad and strong support. Thank you.

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

Thank you.

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

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

Okay, thank you. Is there anyone in opposition to the Bill? See, no one will bring it back to the Committee. Questions or comments from the Committee. Dr. Weber?

Thank you, Senator, for bringing this Bill. And I'm actually going to take you up on your offer to explain, because I was trying to discuss this with my staff, and are all biosimilars interchangeable?

No, it's actually the other way around. All interchangeables are biosimilars. But in order to get the interchangeable designation, it's really a fiscal decision made by the manufacturer. And the intent is whether or not that particular drug is accessed through, like, a CVS or a Walgreens or any other type of pharmacy. And the only real point of doing that is because the interchangeable designation would allow a pharmacist to substitute an interchangeable for whether it's the biologic or another biosimilar.

And so since the bulk of biologic drugs or biosimilars are administered through a hospital or at a clinic or with your prescriber healthcare professional, there's no need to ever seek that interchangeable designation.

Okay. And the only reason why I ask, at least in our analysis, it talks about when you're given that interchangeable diagnosis, but term, when you're given that label, that it has been shown, I guess, in clinical results, to produce the same clinical result as the reference biologic in any given patient. So what you're saying is that biosimilars produce the same clinical result in any given patient, even without that specific designation?

That is correct. The FDA can require. They're not even mandated, but they can require an additional study that's called a switching study. And what that would show is if a patient, first they get the brand, then they get an interchangeable, then they get the biosimilar, then they get the brand again and goes constantly back and forth and moving between the three, that there's no ill effect.

But again, with most biosimilars, it's going to be a one time injection, typically, or very few times would a patient be receiving it. So there would be no need for that interchangeable designation. And there is actually discussions at the FDA on whether those switching studies are truly necessary.

And with this Bill, if a provider did not want their patient to get a biosimilar, they wanted them to get, let's say, the brand name, how would they do that? Is it just written on the prescription brand name only. I know I've had to do that in the past for some of my patients, but those are oral medications, not necessarily IV or IM or subcutaneous. So how would that work in this particular.

So in this circumstance, the prescriber. So if they write, let's go with Lantis. If you write for Lantis, they're going to get Lantis. Or a pharmacy could change it for an interchangeable biosimilar. If you write for the biosimilar, Simgli is the only one on the market right now. Then they would get Simgli. But it comes down to the provider and what they write, the prescription.

So it's not the same as on, like a generic prescription where you write do not substitute or something like that, or check the box. You actually have to write for the biosimilar in order to get the biosimilar without any other interaction from the prescriber. Now, a pharmacist could call and contact a prescriber and say, zero, by the way, there's a significantly reduced 65-85% lower cost option for the biosimilar. Is that appropriate?

But it still takes intervention of the prescriber in order to allow that patient to get the biosimilar.

Okay, great. So the provider would have to write for that biosimilar. It's not something that would be changed at the pharmacist like they do sometimes when we write a prescription and then the patient ends up getting something different.

Just for an interchangeable. You can do that with an interchangeable, but not with a biosimilar without that designation.

Okay, perfect. Thank you.

Did you have a question, Ms. Weldon? Okay. She had a biosimilar question, apparently, but apparently it was answered, so it was all good. Anyway. Any other questions, similar or not seeing? None. The Bill does enjoy a dupast recommendation. Senator, we don't have a quorum. We're getting closer. Would you like to close?

Respectfully ask for your. I vote, thank you. Thank you for the questions. Appreciate it.

Okay, thanks. And we don't see any authors out there, and we don't have a quorum, and we don't have a deck of cards. We don't have any Skittles.

We got a quorum, Madam Secretary. Please call the roll.

[Roll call]

Okay, so we have a quorum. We have a consent calendar items number two, SB 694, Eggman. Item number four, SB 641. Roth. Item number five, SB 19, Seyarto, with amendments. Do we have a motion on the consent calendar? Motion by Ms. Aguiar-Curry, a second by Mr. Villapudua. Madam Secretary, please call the roll on the consent calendar.

[Roll call]

That's 80. That Bill is out. We'll leave the roll open for others to add on. We have item number one, SB 621, by Senator Caballero. Do we have a motion? A motion by Ms. Aguiar-Curry, a second by Ms. Waldron. The motion is do pass to Appropriations. Madam Secretary, please call the roll.

[Roll call]

That has eight. That Bill is out. We'll leave the roll open for others to add on. And now we'll go back to our card games.

Senator, please don't get too comfortable. Come up here. And don't get too comfortable there either. But you please present your Bill.

Right there. Yeah. Have a seat. You've never been in here? Oh, first time this year. Okay. Welcome to the green chair. Would you like to present your bill? Okay, please. You can turn your microphone on, too, if you want to.

Let's see if this works.

Thank you.

Am I good? Coming through?

That's better. Cool. Thanks.

All right. I deserve the freshman treatment, but I'm somehow seven years in now. It's bizarre. It feels like the first time every time. This feels very personal for me. Just went through the end of life for my father-in-law. My wife's dad survived the Holocaust and three wars in Israel and made as a working-class plumber in LA and had a lifetime of trauma, and in the end of his life, went through the pandemic in a nursing home with dementia, and alongside many other seniors in his position and a lot of other positions, both in facilities and outside of facilities, life at the end, or even close to the end, can be isolating, traumatic. And what we learned through the process was, when it comes to medication, a limited range that we're giving to doctors, a limited range of tools that we're giving to doctors who specialize in geriatric care and chronic disease care to be able to help people through it.

So really, all his nursing home had for him to go through a very tough period was things like antipsychotics, antidepressants, morphine, and opioids that the tools that we've sort of put before the nursing care and sort of chronic disease care, elder care industry are limited. And as we sort of went down the decriminalization path around cannabis, there are some unsolved issues I feel are still sitting there in healthcare, around medical use that need to be solved. And to me, this is one of them.

Now, young people have access to unlimited quantities of cannabis in their lives and can use it recreationally at their discretion. But my father-in-law was put in a spot where he literally couldn't be in the facility anymore if we wanted to treat some of his conditions with medical cannabis. We ended up talking to a few doctors and found a tablet that worked for him that you could crush and was very precise, and we same 10 milligrams every morning, and it got him off antipsychotics, antidepressants, and somehow into a place where he didn't need the kind of care that was sort of triggering a lot of other trauma. And I saw the same thing happen.

And this isn't just anecdotal, but people with ALS, where in the last year or two of their life suddenly have been using cannabis in a palliative context at a doctor's discretion. And then when they enter a facility, because of all the liabilities and lack of clarity in the law, you have to basically force yourself off your medication. So this, in my view, is designed to give health facilities, both in facility settings, but also in that sort of palliative care context, the tool of medical cannabis to say, at least don't make that a precondition where you're going to drug test elderly people and say you're off care if you stay on cannabis. That's the situation we're in today. People are literally getting drug tested, and we're trying to remove that, say, as a condition of employment, but somehow now it's a condition of care.

I'm hoping we can remedy that. I know there are some questions, so I'm happy to get into it. But look, this bill isn't going to solve everything. It's going to hopefully remove some initial barriers and then give the medical community and the care community space, I think, to do the kind of really hands-on practitioner work that they can make strong decisions as doctors and as caregivers for what's going to be best for their patients.

And that's why I'm sort of proud to have support and not a position of defensiveness or concern from both health facilities and from the medical providers themselves. I think there's just interest, and it's amazing how immature this space of health care is for how far we've come on the decriminalization side. So I hope that this bill helps other people, not just at the end of their life, but in those later years of life, look to this medicine and try to find alternative ways through trauma. And it doesn't have to be this, but we just want it as an option. So thank you. I know we're accepting some really strong committee amendments. Appreciate the work from the committee. So happy to accept those and answer any questions.

Great. Did you have witnesses?

Yeah. If you want me to lead straight in. You want to go what order here? Let's see. Let me see what my notes say. Bad at. So why don't we start with Dr. Yafai? Okay, so Dr. Sherry Yafai is here with the Society of Cannabis Clinicians.

Thank you. Please push the button there so we can hear you. Thanks.

Is this all right? Okay, perfect. Good afternoon and thank you for having me here today. My name is Dr. Sherry Yafai, and I'm a board-certified emergency medicine physician for nearly 15 years. My work in cannabis medicine did not begin until 2017 when I began seeing patients specifically for cannabis-based treatment. Since that time, I've written a chapter on cannabis medicine for a medical textbook, I've co-authored two research articles on cannabis medicine, I've hosted two medical cannabis conferences for Medical Education, and sat on the Hospital, Pharmacy, and Therapeutics Committee. According to a 2022 study, 73% of patients in long-term adult care facilities are on an opiate medication for pain management. Currently, our options for pain management in these settings are limited. It is imperative to have a nonlethal option for pain management available. According to multiple studies, cannabis-based medicine is one such option.

According to the Medical Board of California, Cannabis is on equal footing to prescriptive medication for the treatment of neuropathic pain. This recommendation is based on the strong foundation of research over the last 20 years. Further studies over the last decade have shown beneficial pain management in the treatment of arthritis and cancer, both diagnoses which affect adults over the age of 65.

Further studies have shown the implementation of cannabis laws and access to cannabis medicine have shown a decrease in opiates prescribed, filled, and as a result, a decrease in opiate overdose. With my remaining time, I would like to present a specific case to the committee. In 2019, I began working with an 89-year-old female with dementia and a recent stroke who was experiencing severe insomnia, agitation, and PTSD after witnessing her daughter's suicide the year before.

On the heels of this catastrophic event, she was moved into an assisted living facility and her surviving daughter was referred to me by a local geriatrician to assist with these diagnoses, I started her on a CBD dominant tincture. That means that it was mostly CBD with a small amount of THC in an oil that she would ingest and a small dose of THC in the form of a chocolate at bedtime. Within two months, she was sleeping well and feeling better during the daytime.

She began engaging in activities that the facility had to offer and living her best life. In fact, her treatment plan was so successful that Providence St. John's Pacific Neuroscience Institute and I have begun working together to assist patients with dementia utilizing cannabis to help with agitation, physical aggression, and insomnia. Nearly four years later, I have about 35 patients with dementia that have been referred for and treated with medical cannabis in non-inhaled formats, with some remarkable outcomes.

Now, studies have shown that patients with dementia live roughly three to five years after this diagnosis, which would mean they are not candidates for Ryan's Law as it stands. According to the Alzheimer's organization, more than 50% of residents in assisted living facilities and nursing homes have some type of dementia or cognitive impairment. Providing options for patients in these facilities to use cannabis medicine is imperative. Our largest challenge currently is to be legally allowed to provide cannabis medicine inside of these large healthcare facilities and home health agencies. It is with this that I am compelled to lend my support for the passage of this bill. Thank you, Senator Stern, for the opportunity, and I want to encourage an aye vote on SB 302.

Thank you.

Next, briefly, and I don't know how much time we have yet, Mr. Chair.

Three minutes.

Respectful. But Mr. Castellblanch with the California Association of Retired Americans.

Am I on here? Great. Chairman Wood, committee members, good to see you all. I'm here on behalf of the California Alliance for Retired Americans. We are a statewide organization that represents organizations with over a million members across the state. I brought this up on our legislative committee call last week. Usually, about 30 people are there. Usually, every bill takes about a half an hour to discuss. I brought this bill up. There was no discussion. It was unanimous.

Before I'd even gotten the last word out of my mouth, somebody said, so moved. Somebody else said, second. And we had a unanimous endorsement from our committee. Letting you know just how strongly seniors across California support this bill. I can't possibly match my colleague over here in terms of research, though I did do a little of my own on the public health implications. Fortunately, NIDA now has on their website information about the efficacy of cannabis for treatment of various ailments. And that's a new thing because, of course, since Nixon, we weren't able to look at cannabis or how it affects people or do any research at all.

So the fact that NIDA is at least making an effort now to say what we can say based on preliminary research, what they show is that it can be a treatment for pain, it can be a treatment for anxiety, effective treatment, which I understand is a very common condition in nursing homes, and also it can be a substitute for opioids. And it's just appalling to think that something like 70-plus percent of people in nursing homes are using opioids for pain. That's really scary knowing what's going on with opioids and the opioid epidemic. So this offers what I would think is a very efficacious alternative for pain management. And I hope that people that are in nursing homes have the right to take this pill. Thank you very much. Or edibles or whatever format they come in. Thank you.

Thank you. Back to the committee for questions or comments. Hang on a second. What did I do wrong? Others in support? I really jumped ahead there, so I was ready to go unanimous with you there. So my apologies. Name and organization if you represent one.

Thank you for the opportunity. Talia D'Amato on behalf of California NORML. We represent consumers, in strong support.

Thank you. Anyone else? Okay, is there any opposition to the bill? Seeing no one, we'll bring it back to the committee now, Ms. Waldron.

Thank you, Mr. Chair. Great bill, thank you so much for bringing forward. I'd love to be added as a co-author if there's any point in the process that can be done. But I was reading in the analysis, and it's shocking that it states that approximately 95% of people over the age of 65 have at least one chronic condition, and about 80% have two or more. Yet we're dealing with an opioid crisis in this country.

And even seniors like my mother-in-law is 89, and pain all the time and trying to get some kind of painkiller, and even the opioids don't work, and it's really hard for them to get it because they don't want her to get addicted to it, and it's the cycle. So having this other option available that has shown a lot of success. Maybe there's still stigma attached to it or whatever, but in the healthcare setting, it's been shown to work in a number of cases. So I definitely support the bill, and thank you for bringing forward.

Thank you. Dr. Weber.

Thank you, Senator Stern, for bringing this up. I think we have seen within the healthcare industry that cannabis can help with certain conditions. Definitely pain, cancer. And I know the father of Ryan and the story behind the bill that his father, Jim Barnett, wrote for this original bill. We know that it helps with seizures. Right? And a lot of nausea and vomiting with our cancer patients, and arthritis, and PTSD anxiety.

So there are certain conditions where cannabis has been shown, either anecdotally and now, hopefully with more randomized clinical trials to show the efficacy. I guess my question is around the definition of chronic disease because it just says a condition that lasts one or more years requiring ongoing medical attention. And when I was talking with some people, I was like, I would guess that a lot of people over 65 have a chronic condition. And it was just stated by my fellow assembly member in the analysis, 95.

And so, chronic diseases, something that you're dealing with for a year, consists of high blood pressure, consists of diabetes, consists of asthma, consists of seasonal allergies. Right? So I guess my question is, and those are not necessarily things that we know at this time that cannabis would be used for. We use it a lot. And all of you have talked about pain. What was the thought process behind having such a broad definition that essentially brings in every single medical diagnosis if you've had it for a year?

I'll send it to the doctor first. But I would just say at the outset, we did want to be that. We did want to be as broad as possible. Used a CDC definition she can talk more about. But the goal, we don't want to micromanage or be hands-on about a doctor-patient relationship and what the doctor themselves, how they want to deal with the geriatric care side and what decisions they want to make about, say, treating dementia. We want all options on the table.

So it was intentional to be that broad because right now you're taking that option off the table. If we were sort of specific about, well, for this, this, and this treatment, say these other areas like dementia, where there's clinical trials going on right now and things like that that people are seeing working, they can't then do that work, and the patient actually can't even just possess it themselves. Right? They can be drug tested. Forget the doctor part. They themselves can be drug tested and kicked off of their healthcare plan now just by possessing it. Anyway, I'll let you comment further.

So, according to the guidelines for the recommendations of cannabis, according to the Medical Board of California, that is actually one of the listed diagnoses. So it's about seven different diagnoses, plus any chronic condition that is indicated by the physician. So it mimics the guidelines that we have under the Medical Board of California.

One of the things that I find beneficial about having that kind of broad of a statement, especially here in California, where it's recreationally legal in the entire state, is that it also gives us some allowances as we're discovering new things where we're finding benefit. As you mentioned, epilepsy was just kind of diagnosed or included in that just in the last five years alone.

So epidiolex, which is what I believe you're referring to, it's a CBD based, hemp based medication that's found indication in seizures and actually two to three specific seizures, Lennox-Gastaut syndrome, Dravet syndrome, and tuberous sclerosis. So seizures that are related to that. What we're seeing is a new study coming out for autism. So CBD indicated for autism. We will be seeing studies coming out on dementia in the next upcoming year.

There was about $20 million worth of grants that were funded just two months ago through the State Department of Cannabis Control to understand and see what other diagnoses we're looking at for treatment purposes. So I believe narrowing the field and just giving us three or four bullet points in terms of chronic illness is a little short-sighted, because then you're just going to keep coming back to this table. Whereas I agree with you, hypertension is not an indication for cannabis use. Right? Hypercholesterolemia not an indication. Those are two very normal chronic diagnoses that 65 and up have right off the bat. Again, it's led to allow physicians to have a little bit of discretion as we continue to really unveil the research here.

Well, I thank you for that answer. It is different than what we normally do because we do have a medication and it's very specific as to what it can treat. We don't usually have. Here's your liberatory. You can treat it for whatever. Right? It's very, very specific. And so that part is just a little concerning. Not concerning enough for me to not support it because I think the idea overall is just, and like I said before, there are some conditions that we do know that this can significantly help. It's just, as was noted in the analysis, chronic disease, it's very broad. And when you're dealing with this particular age group, a vast majority of them have some type of chronic disease, even if it's just you have allergies and you've been having it for a year and now you're being medically treated for it. So now, based on this definition, you're 65. That's your chronic condition. I know.

Over 60.

Sorry, one more clarifying point. So just to add to that. So this is specifically my understanding for nursing homes, home health agencies, all of those have prerequisites both by Medicare and Medi-Cal in order to qualify. So you already have to meet some type of qualifying illnesses and qualifying either physical inabilities or incapacities in order to qualify for this. So we're not talking about a healthy 65-year-old, we're talking about already an ill 65-year-old who's been able to require those chronic illnesses or acute on chronic illnesses that have landed them in a nursing home facility, an assisted care facility, or a home health facility or home health assistance.

So I guess along those lines. So if someone is there for rehab, right, and had not been on cannabis before, but now is in rehab for an injury that happened, let's say, three months ago, but they have a chronic medical condition, which is allergies, they would qualify under that.

Right. But technically, you would be treating their pain that has landed them in the rehab facility.

Okay.

Right. So not the allergy illness, but the one that actually landed them in that facility.

Right. Thank you.

And just to go in, eyes wide open, they could still, the doctor might not prescribe it, they may not be treated for it, but they could still, if they, at their discretion, wanted to possess it and their daughter or son, they couldn't be kicked off their care for using it. That's the other piece of it. Right? So it's not so much trying to tell the doctors, you should be prescribing this for everything.

It's more that it's giving the patients that reassurance also that layer that they may actually get kicked out of the facility or lose their care altogether. That's been a big tension out there, at least in the field, where people have to hide it or whatever it may be. It's getting around that issue, too, and there's all kinds of elements for securing it and storage and safety protocols. But if you do have suggestions going forward, I really respect your deep wisdom on the healthcare field in general. If you have thoughts about just ways to clarify that, the intent here is not to over-prescribe this or to apply it in not medically appropriate context. If you have thoughts on that going forward, very open to working with you or listening. So thank you.

Thank you. Thank you.

Anyone else? Mr. Villapudua.

Thank you to the Chair. So I just want to thank the author. Yesterday we were talking about Alzheimer's and dementia, and as we look at more of the numbers, just growing, trying to figure out what should we be doing. We need to do more, right? So I just want to thank you for bringing this forward, and I'll be moving to vote on this as a second.

Okay. Anyone else? I guess the irony of this is that if you're over 65 and you're not in a facility, you can go to a store and get as much as you want, but the minute you step in there, you can't. And I think that's, quite frankly, kind of ridiculous. I want to say thank you, Senator Stern, for bringing the bill forward and the personal connection you have to this. I'm sure it's shared by a lot of other people. So thank you for bringing that. Thank you to your witnesses. The bill does enjoy a do pass recommendation. Would you like to close?

My wife for taking a chance and working with her dad and our caretakers to look at a different way through the end is a very hard thing to do. She's not like, hey, everyone, we're the pot-smoking household. She's like, no. No drugs and alcohol. They're a conservative bunch by nature. Seeing that work in a family like this and seeing what it can do to let your mind approach pain and even death in a different way, it's a hard topic to talk about, but we got to keep putting on the table. And I just appreciate your consideration here. So respectfully ask for an aye vote.

Very well. Thank you. I think we did. We have a motion. Was that a motion from you, Mr. Villapudua? A second by Ms. Aguiar-Curry. The motion is do pass to appropriations. Madam Secretary, please call the roll.

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

You have nine votes. The Bill is out. We'll leave the roll open for others to add on. So, Senator Limon, thank you. Just press the button, please.

There you go.

Thank you.

Thank you. Chair and Members, food service workers in California must go through food safety training. This training is paid for by the employee, and it's required every three years. Under this Bill, food handlers would still be required to complete the training, but the training would no longer come at the expense of the employee. The employer would be required to pay for the food safety training and the time it takes for the employee to take this training.

For example, currently there are issues and trainings related to asbestos, accident prevention, bloodborne pathogens, fall prevention, ergonomics, fire extinguisher, first aid, among many, many other health and safety trainings that are paid for by the employers. SB 467 would require that the state compile a list of eligible trainings, providing more transparency about the different options. This would serve as a tool for the employer in order to know what options are available and their potential cost.

The state has required employers to pay for other trainings, as mentioned before, and this is a Bill that will protect and help workers ensure that they are trained in relation to food safety training, and that in and of itself is a public good. With me today in support of the Bill, we have Stella Denning. She is a restaurant owner, as well as Mariko Yoshihara, representing One Fair Wage.

Thank you, Mr. Chair and Members. Mariko Yoshihara. I am here on behalf of One Fair Wage, a national organization of nearly 300,000 service workers and 2500 independent restaurant owners. And we are proud to co sponsor SB 476 along with California Labor Federation and SEIU California to end the egregious misuse of worker money through California's Food Handler Training program.

As a Senator mentioned earlier this year, the New York Times had a front cover expose revealing how the National Restaurant Association was using worker money through their Food Handler Training Program called ServeSafe to actually Fund their lobbying activities, which notoriously have been aimed at defeating pro worker legislation. And as you can imagine, these workers were really outraged to learn about this. They have now collectively paid over $25 million to Serve Safe, not knowing that their money was actually being used against them.

Now, this is a public health training. The cost should not be borne on the backs of low wage workers, and especially when those costs are actually driving millions of dollars in profits to very well funded industry groups. The opposition argues that workers should have to pay for this because the certification can move from employer to employer, but in using this argument, they compare this training to other, quote, trainings that lead to licensures that are mandated by law, like a real estate license or a nursing license.

This fundamentally, this is not a skills based license or certification. This is fundamentally a health and safety training to ensure that the food that is provided by the business is safe for the public to consume, which is ultimately the business's responsibility. So from our perspective, there's simply no policy, justification, or rationale for why this particular training program should be paid for by workers and be wholly inconsistent with every other health and safety training that is required by law. So we respectfully ask for your aye vote on this Bill. Thank you.

Very well. Thank you.

Hi, my name is Stella Denig. I am, as was mentioned by Senator Limon, a restaurant owner of a small, independently run, single location restaurant in Oakland, California. We opened a little less than two years ago. It's the first brick and mortar I've ever had, and we currently already choose to pay for this training for our team. We didn't when we opened, and we started halfway through. And I'm here fully in support of this Bill.

And in fact, I'm here to talk about how we've actually seen a positive impact on our bottom line since we made that shift. And to tell you more about that. To be clear, I want to make sure it's clear that what we're talking about is less than $15 for the training and two to four hours of employees time over three years maximum.

In reality, those costs are actually significantly less for us as a business because 50% to 75%, sometimes more of our new hires already come with this certificate because it is required in the industry. And there's so much movement in this industry that workers often are already coming with this training in hand. So the cost to the business is actually significantly lower. And I can definitely speak to firsthand how incredibly challenging it is to make this business work. We're really struggling.

The reality that you've heard about restaurant ownership is true. It's really razor thin margins. And at the same time, when I really look at these numbers in comparison to our total labor, which particularly in a state like California, is extremely high, it's truly nominal in comparison. And I don't use that word lightly in this, really, what I want to specifically highlight is when we shifted from not paying to paying for this training, what happened?

We saw that our employees started taking more time to really understand the materials to do the training because we were paying them for it. So they were incentivized to do that. Whereas before we did that, their labor was being exploited in that process because they weren't being paid for those hours, and they were incentivized to rush through the materials and take the test as quickly as they could make the kind of passing grade. And that's it.

And now where we see financial gains is because people actually know this material. And the reality is that the cost of mistakes in this area is, they're so high on the high end. There's like, lawsuits. There's the liability of potential lawsuits for really intense examples that could definitely shut down our business. And then on the lowest end of it, what we're talking about is comping a guest's meal because we made a small error.

And that cost to us is actually twice as great as the cost of actually paying for this exam. So what we saw when we shifted in doing that was we were actually saving money. This pays for itself in potential orders of magnitude, depending on what we're dealing with. And I think it's also important to note that the liability of mistakes here is on us as restaurant owners. It's not on employees. So really, we need to be paying for this. We are incentivized to pay for this.

It's in our best interest financially and as a business to pay for. You know, lastly, I just want to bring some attention to the. Mariko mentioned this, but restaurant workers are some of the lowest wage earners in America. We had a team Member who told me last week that they had $0.47 in their bank account, and that's at a restaurant that's paying more than twice the standard in this industry.

And I have another employee who shared that they were living out of their car for a year to try to save enough money for a security deposit for an apartment. They couldn't see their kids during that time because of not having a home to house them in. And the impact of this nominal expense to us as a business is not nominal to our employees, and we are incentivized to, and it, in fact, benefits us to pay for this. So I urge an aye vote on this. Thank you.

Thank you. Others in support of the Bill, please come forward in just your name and organization, if you represent one.

Mr. Chair Member. Sara Flocks, California Labor Federation co sponsor in support. Thank you.

Thank you.

Kimberly Rosenberger with SEIU, also in support and co sponsor. Thank you.

Thank you.

Good afternoon. Cassie Mancini on behalf of the California School Employees Association, in support.

Thank you. Is there opposition to the Bill? Please come on up. Yeah, you can come in.

Thank you, Mr. Chair. And Members Matt Sutton with the California Restaurant Association here in opposition to the Bill. We're not in opposition, of course, to the food safety training. We were part of helping craft the training back in 2011 with then Senator Alex Padilla. And so just a little bit of history on that, if you don't mind, because I know it's new to some, and I know there's been comparisons between different types of training.

I guess what I would start with is basically at the time, there was three different health and safety training programs throughout the state. Those still exist today. That was San Diego, County, Riverside County, and San Bernardino. County. Those were not impacted by Senator then Alex Padilla's Bill. So what we're talking about now is a program that was set up over a decade ago very deliberately and with worker protections in mind.

Labor was at the table, as well as restaurants and the health departments to craft the product. There were a number of essential things that went into that, and one is, as was mentioned by one of the proponents, that the certificate be the property of the employee. The other was that it would be portable because food safety is food safety. It should work in all regions throughout the state.

At the time, you had some localities looking to do their own food safety program, so uniformity made sense, and then it would last for three years at a minimum, and there would be choice. There's an open market of many, many providers. Many county departments of Health have lists of providers. ServeSafe is mentioned. ServeSafe, we believe, and most health inspectors believe is sort of best in class, and that's why it's mentioned so much. It's kind of like saying Kleenex for tissue.

But employees have a choice of which provider they use. My son recently decided to use a different one at a lower cost that's completely appropriate and available. And then the last piece is affordability. Don't see this too often, but written into the statute at the time was that a test had to be $15 or less. Here we are, 11 years later, they're as low as $8. So an $8 certificate over three years ends up being $2 and change for the employee.

So at the time, that was deemed an equitable solution to have something that was relatively manageable for the employee, different from what was also mentioned, employer mandated trainings like sexual harassment prevention training and some of the others. So there was an effort to make it distinctly different. All that being said, restaurants are very, very labor intensive, and it is a manageable cost and obligation for the employee under the current program, that's what was deemed appropriate.

But when you take that cost, which could be $50 or $60 per employee and multiply it across the industry, that has 1.4 million restaurant workers throughout the state, that ends up being a real significant cost. 85% of our members are independent restaurants, community based restaurants in your districts. So that is the cost compounding that has restaurants so concerned. It is true there are restaurants that offer to pay for this. There are many that simply can't. So I appreciate the comments made by the restaurateur. Absolutely. But that is the crux of our opposition.

Thank you. Are there others in opposition to the Bill?

Courtney Jensen, on behalf of California Chamber of Commerce, in opposition.

Thank you. Anyone else bring it back to the Committee. Questions or comments from the Committee? Yeah, Dr. Weber.

Thank you, Senator, for this bill. So I have a question for the opposition, because I just heard $50 to $60 per employee, but we've heard $15, max of $15. So where is the $50?

Thank you, Dr. Weber. I appreciate the question. So the actual certificate is what's mandated and allowed to be $15 or less. But you're also under this shifting the cost structure to the restaurant to pay for the time of training. And so when you take even the lowest minimum wage at $15.50, two hours minimum for the course, I guess, is the other piece of information.

So when you look at the time of the training, and I admit the $15 or $8, that's not the significant punch to the restaurant community. It's that time of training, which will vary for people, but we find to be at least 2 hours. So that's how you get up into the $40, $50, $60 per. And it depends on the provider, of course.

Thank you for that clarification. I'll just say this. I've spoken with you, Senator Limon. I think this training is definitely needed, as was stated, for a public health impact and benefit. I understand that many of our restaurants are still struggling and reeling from the pandemic. And we have a different kind of workforce now with a lot of turnover. And I know that we put a lot of rules and regulations and a lot of cost to certain restaurants.

I spoke to a few and they were saying, well, through collective bargaining, there's a lot of things that we pay for for our employees. This is an important thing. I wish that it was actually covered by the state. It is a state mandate for public health benefit, and I believe that it's something that the state should cover and the county should be over. But this is where we are. It's an interesting budget year. So I've told you I will support your Bill today.

But I really believe that this isn't something that the employer or the employee should bear the burden for. It really should be on the state.

Thank you, Mr. Villapudua.

Thank you. I would concur with my colleague. As a former restaurant owner, I get the time that they have to put in, and it's a requirement. The problem I have with it is because of another regulation, especially in my district. I can't speak for all of my colleagues here, but in my district, I got hit hard with restaurants closing. And as much as this number might be small, they're not even paying attention to that.

They're talking to me on a regulation like you keep adding more and more to us, and it is very expensive. I will never get into the restaurant business ever again. It is the most toughest thing to do. I mean, from the minute you open up that door to turning on electricity, to Workman's comp, to insurance, I mean, it is so expensive. And then on top of that is this Bill passes, right? The employer is going to pay for it, but employees can come and go.

They can choose around, take that. And now you're trying to figure out the retention part of it. How are you going to keep retaining employees? And it was heartfelt, what you mentioned your story, that they felt like they would want to be belonging to the restaurant, but that's not the case, especially after the pandemic. I've learned a lot that these restaurants are struggling. I get the author where she's going with this today.

I really can't support it because I get a lot of calls from my business community, which is sometimes really is the backbone of our community. When we're asking for stuff to be paid up here, it's at their expense. And at a certain point I have to say, okay, enough is enough. And I really concur with my colleague that I think that someone going to pay for it really should be the state.

Thank you. Okay. Mr. Rodriguez?

Yes. I also want to thank Senator for bringing this Bill forward. It's obviously important Bill.

I also want to say I agree with my colleague from San Diego as well, that the state should be responsible for this. But just want to share something about the industry I came from. We talked about the restaurant industry, what's happening here with employees, the industry I came from, there were certain certifications and license we needed, and the employer always paid for those, which was never a problem.

The one concerns I'm having is just now that the business also has to pay for the time taken to take that certification. Right? An hour, 2 hours, whatever the case may be. Going back to my examples, I mean, we were given the opportunity that they would pay for it, but nobody was never paid us the time to take those tests or get those certifications that were needed to be that employee of that industry. And it was never a problem.

You talk about the industry that some of these employees are barely making it. Well, that's the industry I came from. I probably had less than a dollar in my bank account after getting my paycheck, paying my bills. So I know what it's like to struggle. But once again, there was never an issue with us as employees at the time taking two, three, even four hours at a time to go get the certification, go get these licenses that we needed.

So I'm struggling with that part a little bit as also that the employer has to pay for the time needed to take that certification. So I'm looking to support it now just as a courtesy. But hopefully you can address some of these things. I don't know how much more you can do because obviously I just started talking to folks about this Bill since yesterday and this morning.

So there's a lot of other things I wanted to talk about, but hopefully you can kind of work with the opposition on some of these other things they're bringing about. And I'll Reserve my right if it comes back to me to support it in a future time. So thank you once again for that.

Anyone else? I see, no one comes back to me. First of all, I support your Bill. Senator, I appreciate what you're trying to do. And I don't know, as a former employer, I think of all the things that I paid for for my employees because I knew that at the end of the day, like our restaurant owner here, that that was going to be a net benefit for me. Flu shots. Whoever wanted a flu shot, I paid for it.

Continuing education, I gave that as an opportunities for my staff. And what that did was it made my staff a better team, more engagement. We were doing providing better care for our patients. And so recognize not every business is in the same position, but I look at some of this as an investment.

But I also got to think that part of the inspiration for this Bill comes from that New York Times article where you have a company that's providing this certificate through training and then uses some of that to lobby and try to depress wages for workers. I have a problem with that. I really, really do. And so I'm happy to support your Bill today. And if it passes out of here, I'd love to be added as a co author with that. Would you like to close?

Yes. Thank you. And thank you Members for the thoughtful conversations and the questions back and forth. And you're right, there is a national conversation happening about this very issue right now in multiple states. We're not the only state that is looking at this particular training and where the fees go.

However, I also come from a family of restaurant owners, and I also have this certification because it turns out that when someone can't show up to work, they have to call a relative to go fill in to help with catering. So I know what it's like to be in a family where people have to pick up and be able to help out to make a business, and a small business in particular, thrive. And that is difficult.

But I also know, as I think was very well articulated here by Stella, which is that the liability, the reason this Bill is coming to Health Committee is because it is a health issue. We can be talking $8, $5, I mean, these are fraction of a cents per day. And you get a lawsuit. And I can tell you, you will not be looking at $50, $100, $1,000 if you have a listeria breakout, it is going to be much more costly.

So from a public health perspective, it is a public good. And the individual or the entity that benefits is the small business. That is what we're trying to protect. We don't want these breakouts, we don't want the lawsuits of mishandling food. And so for those reasons, because at the end of the day, it is the small business that is protected, the employees that are protected.

The example that was given is on the low end, you comp a meal if something doesn't go right, but on the high end, it's a lawsuit. And so $50, $8, $5, there's some free programs out there, right? And that is what we're trying to ensure, that the time that it takes, that no one rushes through something that is going to cost a small business a really hefty tag.

And so I think I respect where all of us are coming from as legislators and the background and experiences that we bring. I, too, wish that the state could pay for a lot of the training that we mandate health and other entities. But that is a different discussion for a different Bill.

What you have in front of you, I think, is our state's version of trying to ensure that we're closing these loopholes, but also ensuring that a public good is met by proper training that is done by the employer to protect the employer from a health mishap with food. So with that, I respectfully ask for an aye vote.

Thank you very much. Senator Limon, do we have a motion by Ms. Boerner? That's right. Excuse me, is there a second? Second by Mr. McCarty, a motion is do pass to Appropriations. Madam Secretary, please call the roll.

[Roll call vote]

You have 10 votes. That bill is out. We'll leave the roll open for others to add on. Excuse me. That was 10 to one. Excuse me. My apologies. Okay. Senator Wiener.

Thank you very much. Mr. Chair, colleagues, I'm here to present Senate Bill 90, the Insulin Affordability Act, which passed the Senate 40 to nothing. Millions of Californians face the fear of being unable to afford the insulin that they need simply to survive.

This bill will alleviate these individuals needing to ration their insulin to save costs. We know that insulin prices have nearly tripled in the past decade, and as a result, one in four people report insulin underuse. Research from USC found that the price increases not because of rising costs, it's because of a variety of factors, including pharmacy benefit managers charging more to supply pharmacies and health plans.

This bill will align California law for many private plans with the federal law that was recently passed that caps insulin copays at $35 for a 30 day supply. We made various amendments to the bill in the Senate, particularly focusing the bill on tier 1 and 2 plans, and I respectfully ask for your aye vote. With me today to testify is Sarah Steigers a patient and Lisa Murdock, chief advocacy officer with the American Diabetes Association.

Okay, please go ahead. We have a motion.

Hi. Thank you so much, Mr. Chair and members, we're very grateful to have the opportunity to talk to you about this bill today. There is a national conversation about the price of insulin and what that impact has been on people with diabetes. We have 24 states, plus the District of Columbia that have approved cost-sharing measures to make this drug more affordable. No one's really standing in line because they want to take insulin. They're taking insulin because they have to.

I'm going to yield the rest of my time to one of our volunteers, who's going to talk to you about her own experience with insulin affordability. Thank you.

Good afternoon, Mr. Chairman, members. My name is Sarah Steigers, and I've been living with type one diabetes for 11 years, a disease for which there is no cure. I'm a proud Los Angeles native and resident, a master's of public health and health policy candidate at UCLA, and a Member of the American Diabetes Association's Southern California Advocacy Committee.

And I, like nearly 4 million other Californians with diabetes, rely on insulin as my only treatment option. However, the rise of insulin prices has made the drug unaffordable for roughly one in four insulin users who report rationing their doses to pay for other life essentials, including rent, utilities, food, and childcare. Rationing insulin takes many forms and has many faces, and every year it causes death and severe medical complications among my community.

I have experienced times of rationing insulin as a young professional, even with employer based insurance, due to the astronomical cost of copayments, and my health has suffered as a consequence. Once, while being rung up at the pharmacy counter, the pharmacist was shocked to see the total cost of my bll, so much so that he double checked the receipt and said, "That's a car payment," and it was to cover all of my insulin prescriptions. I was looking at a bill of over $400, which was not irregular.

That's over $400 in insulin alone. No insulin pump supplies, no doctor's visits or glucose monitoring supplies, no laboratory copayments, needles or syringes. Just insulin, a drug for which I have no choice but to find a way to pay for or risk my life in its absence. However, change is possible. In 2022, we saw Congress pass the Inflation Reduction Act, which contained provisions ensuring Medicare beneficiaries don't pay more than $35 per month for insulin.

24 states and the District of Columbia have also capped monthly cost sharing on insulin. Similarly, this bill will prohibit California's state-regulated health insurance plans from imposing deductibles on insulin prescriptions or imposing a copayment of more than $35 for a 30-day supply of an insulin prescription. Passage would mean taking large, equitable steps towards insulin affordability that is desperately needed for so many.

Analysis on previous versions of this bill from the California Health Benefit Review Program found that capping cost sharing on insulin would not raise premiums for California by even 1% and would reduce costs associated with diabetes related emergency department visits by 10%. Therefore, we would like California to choose to take action that mirrors that of Congress and states across the country and recognize that ensuring insulin is affordable makes sense fiscally and is impactful in creating more positive health outcomes. Thank you.

Thank you. Do we have others in support of the Bill?

Faith Borges, on behalf of California agents and Health Insurance Professionals, in support.

Thank you.

Amy Brown on behalf of the City of Los Angeles, in support. Excuse me. Long beach in support. Thank you.

Thank you.

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

Thank you.

Good afternoon. D'Artagnan Byrd with Ask Me California in support. Thank you.

Thank you.

Alex Khan on behalf of the California Chronic Care Coalition in support.

Thank you. Anyone else? Is there opposition to the bill? Would you like to come up?

No, it's going to be pretty brief. Is that okay?

Okay. Good afternoon Chair and members of the committee, Robert Boykin with the California Association of Health Plans here respectfully in opposition to the bill in print. First, we want to make clear that we absolutely understand and sympathize with the patients who are burdened with the high cost of insulin.

Sure.

We have continually and vocally expressed that addressing the high cost of prescription drugs within our healthcare system is critical to maintaining affordability for our enrollees. We share and release frustrations that the exponential rise of prescription drug prices, including insulin, continues to drive up costs within our healthcare system. However, thanks to increased competition, political pressure, and recent changes in federal laws, the inflated price of insulin is finally starting to come down.

We would be open to a conversation with the author that would delay the effective date of this bill and apply the tiering structure equally to all markets, individual, small and large group, in order to make implementation smoother. Health plans remain committed to providing comprehensive coverage that helps our enrollees prevent, diagnose and manage both acute and chronic conditions that promote health, wellness and prevention.

We look forward to continuing to work with the author and legislature to ensure that Californians have access to insulin at a competitive and transparent price. Thank you for your time today.

Thank you.

Mr. Chair, members. Steffanie Watkins, on behalf of the Association of California Life and Health Insurance Companies, in the interest of time, I'll echo my colleagues' comments. I would just highlight on the implementation date. We've seen this in a couple of bills that there's two different dates. Just for the ease and quality of implementation across all market segments. We would like to have a further conversation about merging those dates and having one implementation date that would go across all market segments.

For those reasons, we remain opposed to the bill, but we look forward to having future conversations.

Great. Thank you. Anyone else? Others in opposition, please.

Preston Young from the California Chamber of Commerce here today in opposition. I allign my comments with those from ACLU and CAP. Thank you.

Okay. Thank you. Anyone else? Okay, let's come back to the committee. Questions or comments from the committee? Ms. Waldron?

Thank you, Mr. Chair. Thank you, Senator Wiener, for bringing this bill forward. I'm happy to be a co-author. It will help lower the cost of life-saving insulin for Californians who depend on it. And we know that the costs have skyrocketed over the last few years. I think it was average list price of brand name insulin nearly tripled between 2007 and 2018, increasing by 262%, compared to an average of 159% for all drug classes.

I've been involved with this issue for many years, as well as working on other chronic conditions and trying to get more streamlined access to needed medications. So we need to make sure that patients have access to the life saving treatments in the long run. It saves money, just the prevention of what could be hospitalizations or other things, and also helps for successful adherence to these drugs, which leads to better stability and outcomes. So I'll be supporting the bill. Thank you.

Thank you. Anyone else? First of all, thank you, Senator Wiener, for bringing this bill forward. Appreciate what the Federal Government has done, but that wouldn't have helped your witness, who I would guess is probably not on Medicare. Yeah, I didn't think so. Yeah. Looking pretty young there, and I do appreciate where we've heard from opposition that the price is coming down for insulin, but there's no guarantee it's going to stay down.

And in reality, if the price is just coming down, it probably could have come down a long time ago. And one of the reasons that there was a bill to actually have the state begin producing its own insulin was because of the high price of insulin. And that is the effort to make sure it's affordable, period. And so I do actually share one concern of the opposition, and that's the uneven implementation date here. I would rather see this all, quite frankly, take effect January 1, 2024.

And basically, it's the individual or small group market that isn't going to go into effect until January 1, 2025. And some of that, quite frankly, is Covered California. And so the uneven implementation of that I find really frustrating. And I would hope that if Covered California is listening that maybe they can figure out how to get this in so we could actually have an effect for everyone in January 1, 2024. With that, would you like to close, Senator Weiner?

Thank you, Mr. Chair. Yes. Covered California and the Senate was quite insistent on a delayed implementation. So that happened in Senate health. And I'm aligned with you in terms of my viewpoint, but that was the amendment in the Senate. So, first of all, I'm very grateful that this is a bipartisan bill. It should not be a partisan issue. Diabetes affects everyone, red and blue, and this is just a huge issue. And, yes, we have a lot of work to do on multiple fronts around cost of insulin.

And it's great that the state will, I hope, be producing insulin. It's great what's happening with some of the pharmaceutical companies. But ultimately, when the consumer, when the patient is going to get their insulin from the pharmacy, what they see is the copay. Everything else is a bunch of industry giants who might be fighting with each other. That's great. They can fight with each other, and government can get involved. We can try to work it out.

What the patient sees is walking the pharmacy, and the pharmacist says, $100 for your next month's supply. Well, I don't have $100. Well, then you can't have your insulin. That's what we're fixing today. And I'm so appreciative for the bipartisan support, and I respectfully ask for your aye vote.

Thank you very much. We have a motion by Ms. Aguiar-Curry, a second by Ms. Boerner. The motion is do pass to appropriations. Madam Secretary, please call the roll.

[Roll Call]

That's 14, zero. So thank you very much. Your bill is out, and that is the presentation of all the bills. So we'll go back to the top of the order, and we'll go through this one time. We'll go to the top of the order. Item number one, SB 621. Please. Madam Secretary, please open up in the roll call the absent members.

Arambula. Arambula, aye. Boerner. Boerner, aye. Wendy Carrillo. Wendy Carrillo, aye. Flora. Maienschein. Maienschein, aye. Joe Patterson. Joe Patterson, aye. Santiago. Santiago, aye.

That's 14, zero. Items number two, four and five are the consent calendar. Please, Madam Secretary, please open the roll. Call the absent members on the consent calendar.

Arambula. Arambula, aye. Boerner. Boerner, aye. Wendy Carrillo. Wendy Carrillo, aye. Flora. Maienschein. Maienschein, aye. Joe Patterson. Joe Patterson, aye. Santiago. Santiago, aye.

That's 14, zero. Item number three, SB 476. Madam Secretary, please open the roll, call the absent members.

Waldron. No. Waldron, no. Flora. Joe Patterson. Joe Patterson, no. 10 to three.

That's 10 to three. Item number six, SB 302. Madam Secretary, please open the roll, call the absent members.

Arambula. Arambula, aye. Boerner. Boerner, aye. Wendy Carrillo. Wendy Carrillo, aye. Flora. Joe Patterson. Joe Patterson, aye. Santiago. Santiago, aye.

That's 14, zero. And finally, item number seven. SB 90 by Senator Wiener, please. We got the same. So it's 14, zero. That means we are done. So I adjourn the meeting. Thank you.