Assembly Standing Committee on Health

Well, thank you so much. And I am so sorry to the colleagues and Mr. Chair to keep you waiting, but thank you so much for this courtesy. I'm here to present SB 487, which is focused on abortion provider protections. It's a critical component of California's efforts to shield and enhance access to reproductive services and abortion care. This Bill is needed to help protect providers who provide abortion and gender-affirming care to people from out of state. Essentially, it would help safeguard California providers from additional sanctions.

The aftermath of the Dobbs decision overruling Roe not only eliminated 50 years of reproductive freedom, but also emboldened states to enact their own bans and restrictions, with many passing laws to target providers. While many of the states with abortion bans do have limited exceptions, providers are becoming increasingly wary and discouraged from entering the reproductive health field altogether.

With a shortage of access to care in other states, people who need abortion care are coming to our state because they can't find a provider or they can't find one willing to take the risk in their home state. We're also seeing some of our providers traveling to other states to provide abortion care services.

The purpose of SB 487 is to protect California healthcare providers who are willing to take risk by providing abortion care and gender-affirming care in other states from additional sanctions, as well as providers who provide those services in California, for people from out of state. This bill would shield providers from retaliation and repercussions so that there is no disruption in their ability to perform abortion care in California, where abortion care is legal and enshrined in our state constitution.

SB 487 is narrowly crafted, and this is important, and in no way limits or restricts our existing consumer protections or the ability of the Medi-Cal program to terminate providers for other nonabortion health care reasons. In California, abortion care is health care, and our providers deserve peace of mind, not persecution or prosecution. So I respectfully ask for your Aye vote. I'm happy to take comments or questions. I have two key witnesses. With your permission, Mr. Chairman.

Yes, please go ahead when you're ready.

Thank you.

Good afternoon, Chair Wood and Members. My name is Pana Lawsey, and I am a family medicine doctor from Sonoma County and a Board Member of the Maya Network. I'm here in support of Senate Bill 487, which will protect California healthcare providers from adverse actions on our licensure based on another state's law which interferes with the right to access care here in California. One year since the fall of Roe, 20 states have banned or severely restricted access to safe and legal abortion.

I travel to Kansas regularly to provide abortion for patients who come from all over the Midwest and Texas. While abortion is legal in Kansas, the Attorney General is anti-abortion, and there is a real possibility that they would support an action on my Kansas license from a hostile state. When I am in Kansas, I am very conscious that a fellow family medicine, Dr. George Tiller, was murdered there. I take the risk knowingly, but I really appreciate California having my back when I return home.

It is important for providers to be able to care for patients without fear of retaliation as a result of another state's harmful policies which interfere with access to care. SB 487 will protect providers who are offering crucial life-saving care to patients. To ensure I can continue to do my job, I urge you to support this Bill today. Thank you so much.

Thank you. Please.

Good afternoon. Alexis Rodriguez with the California Medical Association, representing nearly 50,000 physicians and medical students across the state, proud co-sponsor of SB 487. Since the Dobbs decision was issued, abortion providers and their patients have faced an increase of new and unprecedented attacks on abortion, including efforts to criminalize this safe and effective healthcare procedure. Today, 20 states have enacted total or severe bans on most abortion services and this number continues to change as new states introduce bans and criminalize health care.

With the legal uncertainty, California must do everything we can to ensure that our providers in this state can continue to provide comprehensive health care, including abortion and gender-affirming care. SB 487 would provide additional safeguards for California's abortion providers and protect their ability to serve patients that may reside in states with hostile abortion laws. This Bill would ensure that providers are not punished for providing care that is a fundamental right in this state.

It protects the patients in most need of affordable and accessible care, ensuring they can continue to receive it from trusted providers. With that, I respectfully ask your support today. Thank you.

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

Hello, Karen Stout on behalf of NARAL pro-choice California, as well as the California Nurse Members Association, in support. Thank you.

Thank you.

Hi, Tiffany Matthews, on behalf of Attorney General Rob Bonta, in support.

Thank you.

Mr. Chair, Members. Paul Yoder, on behalf of the California State Association of Psychiatrists, in support.

Thank you.

Ryan Spencer, on behalf of the American College of OBGYNs. We're co sponsors of this measure. In support.

Thank you.

Craig Polsfer on behalf of Equality California, in support.

Thank you.

Janelle Louis, on behalf of Eleni Kunalakis, Lieutenant Governor, in support.

Thank you.

Tim Madden, representing the California Chapter of the American College of Emergency Physicians, in support.

Thank you.

Jen Chase from the University of California, in support.

Thank you.

Ronnie Rodriguez, on behalf of the California Hospital Association, in support.

Thank you.

Kathy Mossberg, Central Access Health, in support.

Thank you.

Matt Lege with SCIU California, in support.

Thank you.

Taylor Jackson, on behalf of California Health Plus Advocates representing California's 1300 community health centers, in strong support.

Thank you.

Serena Nuran on behalf of Planned Parenthood Affiliates of California, co-sponsor, in strong support.

Thank you.

John Shaban, on behalf of California Nurses Association, in support.

Thank you. Is there opposition to the Bill? Seeing none. We will bring it back to the Committee for questions or comments. Any questions or comments from the Committee? Dr. Weber.

Good afternoon, Senate Pro Tem Atkins. I really just want to speak up and thank you so much for introducing this Bill. As one of those providers, who in my formal life, provided abortion care, I know that it is extremely important for us to be able to do our jobs, provide the best care, and not necessarily worry about whether or not we will have served any repercussions in this great State of California. So thank you so very much.

Anyone else? Seeing no one. We are short a quorum. It's not unusual, but it usually resolves itself at some point. And the Bill does enjoy a do pass recommendation. Would you like to close?

Just to say thank you so much, Mr. Chairman. Thank you. Just support this. Ask for your Aye vote.

Thank you. Should the Bill pass out a Committee, I'd love to be added as a co author, if you'd have me. Thank you. Thanks very much. Okay. See, we have Mr. Wiener present. We don't have any other authors, so Mr. Wiener, you're welcome to come up. Thank you, sir. You have more than one Bill.

None of them as controversial.

No not at all. Not at all. We'll start in file order. So item number 12, SB 70.

Actually, Mr. Chair, if it's possible, on SB 238, I have a witness who has a travel issue, so I don't know if it's possible to go out of order.

Yeah, we can do that.

Okay, I appreciate it. Thank you.

It's been an unusual day, so we're willing to do almost anything.

Thank you very much, Mr. Chair and colleagues, I'm presenting Senate Bill 238. SB 238 is designed to expand access to behavioral health treatment for young people. And specifically, what it will do is that if a health plan denies mental health treatment coverage for a young person, an independent medical review will be automatically triggered. We know that today when IMRs are requested by a family for their child, the family is overwhelmingly successful in overturning the health plan denial.

Unfortunately, many families do not even know that they have this option, and overwhelmingly, IMRs are requested in English. And so we know that there are major inequities in terms of different communities not requesting these IMRs. So this will automatically trigger the IMR. We think it'll expand access to mental health care for young people who have been struggling so mightily in recent years. And I respectfully ask for your Aye vote.

With me today are Janelle Batalia, a social worker from San Diego, from the San Diego Center for Children, and Colleen Corrigan from Children Now.

Please go ahead. You have to push the button there, though.

Good afternoon, Chair Wood and Members of the Assembly Health Committee. My name is Janelle Battalia. I'm here in strong support of SB 238. I'm a licensed clinical social worker and the Director of Business Development at San Diego Center for Children. We provide a range of mental health services for families, including a 24-hour residential treatment center for those with the highest level of mental health need.

San Diego Center for Children is also a Member of the California Alliance of Children and Family Services, a supporter of SB 238. From our vantage point of a nonprofit organization working with vulnerable children, youth, and families with mental health needs, we have served more families than we can count who have been denied coverage by their insurance company. And I am here to share one family's story. I have changed the youth's name and certain details to protect his privacy.

Matthew is a 14 year old boy who came to our residential program last year after three back to back hospitalizations for attempting suicide. He was hearing voices telling him he was worthless and should kill himself. Before being adopted by a relative he calls Mom at age five, Matthew had been terribly abused by his biological parents. Suffering from PTSD, Matthew was taking five different medications.

After three weeks in our program, Matthew's insurance company denied any additional days, stating that he no longer met medical necessity, despite his psychiatrist recommending further treatment. Hoping the appeal process with her insurance company would change that result, Matthew's mother took out a loan awaiting the outcome of the appeal process. However, after two weeks, the mother had exhausted her financial resources and without other options, she took Matthew home. After waiting another week, Matthew's mother learned the appeal was unsuccessful.

Only then could Matthew's mom file a complaint with the Department of Managed Healthcare. When I reached out to help her with this process, I learned Matthew had just been re-hospitalized following another incident of harming himself, which involved the police and a trip to the Emergency Department. The mother told me she needed to focus all of her efforts on keeping Matthew safe and finding outpatient treatment that would be covered by her insurance.

These immediate needs were all she could focus on while having a full-time job and supporting two other children. Matthew's mom is still paying back her loan, and she believes if Matthew had been able to stay in our residential program for the recommended amount of time, he would not have been hospitalized again. Stories like Matthew's are unfortunately not uncommon in the mental health field.

We frequently see parents faced with an awful choice after a denial. End treatment and take the risk of their child's condition worsening, or take on significant financial hardship to continue treatment. Placing the entire responsibility on families to initiate an IMR is a recipe for failure. In all but rare exceptions, families in crisis simply do not have the resources. SB 238 represents one solution that would have a direct and positive impact on children like Matthew and so many others. Thank you.

Thank you. Please go ahead.

Good afternoon. My name is Colleen Corrigan and I'm a Peter Harbidge Fellow this year with Children Now, a state-based research and advocacy organization focused on children's health, education, and welfare. Having worked in behavioral health for years, our organization has heard from countless providers and families about the difficulties in navigating the independent medical review process. While IMRs are an important consumer protection, it places the burdens on enrollees and delays or prevents youth in California from receiving critical, timely mental health treatment.

It is difficult to access for families who speak other languages other than English and who do not have the health, literacy or time to submit a grievance and subsequently file an IMR. Children are most susceptible to the long-term effects of undiagnosed and untreated mental health, including unnecessary disability, unemployment, homelessness, inappropriate incarceration, suicide, and billions of dollars lost in productivity. Mental illness is killing California's youth.

Suicide is the second leading cause of death in youth between 15 and 24, and suicide rates among black youth doubled between 2014 and 2020. California's youth mental health crisis has become a full-blown emergency, and SB 238 aims to protect more kids from falling through our safety nets. Years of IMR determinations demonstrate that the majority of mental health denials for youth are later overturned by IMR. We have no way of estimating how many youth are denied care because plans are not required to report those numbers.

Our team has had months of conversations with advocates and providers to draft legislation that is consumer-friendly and consistent with existing law, and we'll continue to do so in regard to patient privacy. Health plans are only denying these treatments because the system currently allows it. We need to ask for accountability from health plans and how they deny and approve this lifesaving care. We must act now to address racial and economic inequities in mental health because early intervention is the key to recovery. Thank you.

Thank you. Others in support. Just your name and organization if you represent one.

Mr. Chair and Members, Paul Yoder on behalf of the California Academy of Child and Adolescent Psychiatry and the California State Association of Psychiatrists, in support.

Thank you.

Adrian Shelton on behalf of the California Alliance of Child and Family Services, in support.

Thank you.

Samaya Nahara, on behalf of MCG Health, in support.

Thank you.

Lisa Gardner on behalf of the County Behavioral Health Directors Association, in support.

Thank you.

Randall Hager on behalf of the Psychiatric Physicians Alliance of California. Thanks.

Great. Thank you.

Danny Thirakul on behalf of Mental Health America of California and the California Youth Empowerment Network, in support.

Thank you.

Rebecca Gonzalez, National Association of Social Workers, California Chapter, in support.

Thank you.

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

Thank you.

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

Thank you.

Jennifer Alley with the California Psychological Association, in support.

Thank you.

Paul Simmons with the Depression and Bipolar Support Alliance of California, in support.

Thank you.

Rachel Mueller on behalf of Weideman Group with the California Society of Health System Pharmacists in support. Thanks.

Thank you.

Brandon Marchey, with the California Medical Association, in strong support.

Thank you.

Dean Graffilo with Capital Advocacy on behalf of the California Life Sciences, in support.

Thank you.

Johann Cardenas with the California Pan-Ethnic Health Network, in support.

Thank you.

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

Thank you.

Nicole Wordelman on behalf of the Children's Partnership, in support.

Thank you.

Tim Madden, representing the California Chapter of the American College of Emergency Physicians, in support.

Thank you.

Dartagnan Burr on behalf of Ask Me California, in support.

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

Mr. Chair and Members. Stephanie Watkins on behalf of the Association of California Life and Health Insurance Companies. Unfortunately, we do have an opposed unless amended position, which is a recent change from our original position. While it goes without saying that mental health is a key component to a person's overall well-being, and health plans and insurers remain steadfast in our effort to provide safe evidence-based behavioral health care in accordance with existing state and federal requirements.

While we appreciate the overarching goal of ensuring enrollees and insured have access to important medically necessary mental health services, we are concerned about the Bill as drafted is missing several key considerations that could result in all patient access to healthcare being delayed. With that in mind, we have proposed amendments to address some of our outstanding concerns regarding process and patient privacy.

Our goal with the proposed amendments is to retain what we understand the author's intent is to allow enrollees and ensure the option of accessing IMR process sooner, while also protecting the integrity of the system. Generally, what we are suggesting, and we would enjoy future dialogue and conversation, we've had some good conversations so far, is the possibility of the provider versus the plan sitting in the role of making that determination. Whether or not to go directly to IMR versus going to the normal grievance process.

The concern we have is if everything goes directly from the department to IMR or for the plan to IMR, we're going to bog down the IMR system with things that inevitably may be canceled at the back end, which is a concern, and we think that will delay and overrun the IMR system. So our goal would be to look to providers who we think are uniquely qualified and also with a direct relationship to the patient to make those determinations if something should go directly to IMR versus go through the normal grievance process.

We think that addresses the privacy concerns as the patient would then sign off with the provider to submit on behalf of IMR. We'd love to continue those conversations. We think it's a key component and an important piece of it. And so we look forward to the possibility of the author and the sponsors considering this as we move forward.

Okay, thank you. Thank you. Please go ahead.

Good afternoon, Mr. Chair and Members of the Committee. Jed Hampton with California Association of Health Plans. We are also in an opposed unless amended position, like our colleagues, Robert Aclic. Again, we would like to thank the author and the sponsors, and the Committee staff. We have had several conversations on this Bill over the past several months. As my colleague mentioned, we did recently settle on a series of proposed amendments.

We realized that they were just submitted very recently, so there's still some more time to discuss that. But I have appreciated the author's office and the sponsors maybe taking a look at some of those and just again, find a way to address some of our concerns around privacy and process while ensuring that the intent of the Bill remains intact. So, for those reasons, as of now, we are opposed unless amended the Bill. Thank you.

Thank you. Others in opposition?

John Wenger on behalf of America's Health Insurance Plans, also opposed, unless amended.

Okay, thank you. Seeing no one else. We will bring back to the Committee. Questions or comments from the Committee? I do have a comment and actually a question or suggestion. When I met with Senator Wiener, when I met with the opposition, I think one of the things that came up is that sometimes we call them adverse claims experience, which I call a denial. But anyway, sometimes those are on technicalities. So, in other words, a box may have been not filled in or something very simple to rectify.

And if that happens, then that goes to IMR. That, in my mind, could actually delay the process. So there needs to be some mechanism for a simple data box missing or something to be able to make sure that that doesn't happen because I think that would undermine what you're trying to do. So is that part of the discussions? Or if it's not, it should be.

So we've been in regular discussion with the plans, and that will continue. The most recent concern that they've raised, we're actually in discussion with the different provider groups because they're suggesting the providers have a particular involvement in triggering IMRs. And obviously, we want to know how that works on the ground. Yes. And we're happy to take that into consideration as well, but we're in an ongoing conversation with the funds. We want to get this right, and we appreciate that they're coming up with at least some potentially constructive thoughts, and we'll continue to have that dialogue.

And I guess the other concern I would have is that there are so many changes sometimes in law and policies that how do we ensure, if you were to go, as the opposition is suggesting, having the provider initiate the IMR process. How do we make sure that the providers actually know these options exist? There's an onus, I believe, on the education in this, and it's all part of the process. I'm not trying to micromanage your Bill, but I think there's some valid things that have come up here and it seems to be a willingness to continue to work together. So I thought, I have two cents so I want to throw them in and see where they land.

And it's a two-way street. We're definitely going to continue to have dialogue. And like I said, we're talking to CMA and other provider groups about just making sure that we're, again, sort of ground-truthing how this would work in practice.

Thank you. The Bill, we don't have a quorum, actually. We have shrinking numbers, so it might be a while. Would you like to close?

Respectfully ask for an Aye vote.

Okay. The Bill does enjoy do pass recommendations, so when we have a quorum and a motion, we'll bring it up for a vote. So thank you to your witnesses.

Thank you.

So how about SB 70 now? We're good for that? Okay. Thank you.

Thank you, Mr. Chair and Colleagues. Senate Bill 70, the Medication Access Act, is a narrower but still very impactful reintroduction of last year's Senate Bill 853 which did pass through this Committee. 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 by a provider to a different drug for non medical reasons, such as cost. That's an existing protection in California law.

SB 70 would add to that protection, dose level and dosage form for the same drug so that if a provider decides that a particular dose or a particular dosage form is appropriate, the health plan would not be able to force a different dosage form or a different dose. The amendments that we are proposing and accepting today are technical in nature, as proposed by the California Department of Insurance to make sure that we have equivalency between CDI and DMHC.

We know that many Californians experience chronic illness and rely on prescription medications to live functional lives. I've been very transparent. I'm one of those people. I have Crohn's disease, and thankfully, I'm able to have access to medication that gives me a good quality of life. For some of these illnesses, like inflammatory bowel disease, there's a limited number of treatments available, and optimizing the dose can have huge, positive impacts for a patient's life, and if they're forced to switch to a different drug or a different dose or a different dosage form, it can be debilitating.

So medical professionals do a lot of work to try to optimize the medication, and those decisions should be respected. SB 70 will strengthen patient stability and well-being, and I respectfully ask for an aye vote. With me today is Ryan Spencer testifying on behalf of our sponsor, the Crohn's & Colitis Foundation.

Please go ahead.

Thank you, Mr. Chair. Ryan Spencer on behalf of the Crohn's & Colitis Foundation, the sponsors of SB 70. First like to thank the Senator for authoring this important measure. One of the key missions of the foundation, and what you'll hear from me the most, is helping IBD patients find medications that work and to make sure they stay on the drug for as long as they are stable. This is because not only of the scarcity of the medications, but because of the patient's response to a particular medication.

Finding the right medication that keeps the patient stable, as the Senator mentioned, is gold, and that is why physicians will do whatever they can to make sure the patient is able to stay on that drug. This becomes an issue when, after a period of time, the effectiveness of the medication begins diminish due to changes in tolerance. When this occurs, the provider is left a few options. One is to find a new medication, which, as mentioned, is the risk the new drug may not be as effective, if effective at all, as the one currently prescribed.

So ideally, the physician would want to optimize the existing drug to its fullest extent, and this can be achieved by increasing the dose, also known as dose optimization. In the case of Crohn's patients, this could mean instead of receiving a medication infusion every eight weeks, they would go every six weeks.

When this occurs, the patient's response to the drug typically increases, allowing them to remain stable for a longer period of time. Even though current law as prescribed by the non medical switching provision protects patients from losing their currently prescribed and covered drug, it does not apply when managing the drug's dose. Every change in the dose of this currently prescribed and currently covered drug must be approved by the health plans, and as we have seen, these requests are routinely denied.

Once denied, the patient must go through the appeals process. First the plan's internal appeal, and then the Department of Managed Health Care's independent medical review. This process can go on for weeks while the patient waits and hopes the condition does not worsen. What is frustrating on the results of a 2021 unofficial internal audit of the IMR: this audit found that 87 half percent of IBD patients who appealed their insurance medication denials eventually had the request approved.

This means that during the review period, when they should have had their access to a drug, should have access to an optimal dose, they didn't, and as they waited, their condition may have worsened, forcing them to switch to potentially less effective drug and risking stability. It should be noted this switch is not temporary. Once you switch from a drug, there's no going back to it. And keep in mind, this is only for those who even know that appeal is even available to them.

The goal of SB 70 is simple: strengthen non medical switching law so that it can keep patients on a currently prescribed and currently covered drug, which mean that if an increased dose is necessary to accomplish this goal, that dose should be protected too. We're not talking about experimental drugs. We're talking about a drug that the plan already agreed to cover for that condition. SB 70 is a regional approach, and we ask for your aye vote. Thank you.

Thank you very much. Others in support of the bill?

Tim Madden representing the California Rheumatology Alliance, in support.

Thank you.

Emily Wood, Chair of the California State Association of Psychiatrists, in support.

Thank you.

Sumaya Nahar on behalf of the Children's Specialty Care Coalition in support.

Thank you.

Brandon Marchy with the California Medical Association in support.

Thank you.

Jessica Hay with the California School Employees Association in support.

Thank you.

Tara Gamboa-Eastman with the Steinberg Institute in support.

Thank you.

Dean Grafilo with Capital Advocacy on behalf of California Life Sciences in support.

Thank you.

Mel Assagai for the California Association of Orthodontists in support.

Thank you.

D'Artagnan Byrd, AFSCME California, in support.

Thank you.

Michelle Rivas, California Pharmacists Association, in support.

Thank you. Anyone else? Okay, seeing no one. Is there opposition to the bill?

Good afternoon, Mr. Chair Members of the Committee. Jedd Hampton with the California Association of Health Plans. Regrettably, we are here in opposition to SB 70, which would indefinitely limit a health plan or insurer's ability to review any changes that are made to an increase in medication or change in the dosage form of an existing prescription for our enrollees. We would like to thank the author and the sponsors and the Committee staff.

Again, we've had several several good conversations around this Bill over the past year and a half, so really appreciate the openness to discuss. Health plans rely upon 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, from our perspective, SB 70 would remove our ability to review clinically appropriate use of prescription drugs when the dosage of a medication is increased or the dosage form has changed, which we believe will lead to several unintended consequences. Stripping health plans of the ability to provide clinical oversight when these changes are made could lead to an increase of potentially adverse reactions associated with the changes in dosage or dosage form.

And by dosage form, I mean things like going from a pill form medication to a self-administered injectable. In instances where health plans choose to limit a dose of a drug or its dosage form is generally to ensure that these medications are used safely, consistent with FDA-approved labeling and prescribed doses that have been studied or shown to be efficacious.

While we appreciate that this Bill attempts to construct a framework to ensure that the changes in dose and dosage form are prescribed safely, we are concerned that this Bill does not consider the full Clinical Compendia recommendations, especially around off-label uses and doses. Additionally, we are concerned that taking away the health plan's ability to provide clinical oversight could encourage the use of expensive specialty and brand name drugs when a generic or lower-cost brand equivalent is available and clinically appropriate.

We do acknowledge that this Bill is primarily focused on Crohn's and Colitis, but we would point out that this Bill is not limited to Crohn's and Colitis Foundation. This is all drugs, all prescriptions. So when we talk about increases in dosage or dosage forms, That's generally our overarching concern. Lastly, we believe that SB 70 will lead to increased costs in healthcare delivery.

The California Health Benefits Review Program's analysis of SB 70 made several key assumptions in their analysis that may potentially conflict excuse me with our understanding of the intent of this Bill. The CHRP analysis assumes that health plans and insurers would still be able to use utilization management protocols if changes are made to the dose or dosage form.

And our understanding is that the intent of this Bill is to remove our ability to utilize these protocols, which would have the impacts that I previously mentioned, while amendments were excuse me. Additionally, the CHRP analysis also assumes that the health plans would have the ability to adjust cost sharing year to year based upon the renewal of the policy or contract.

While amendments were taken in the Senate attempted to address this issue, we believe that the current language would still allow for the manipulation of cost sharing amounts within a plan year, which we believe could still increase the premium impact of this Bill and could be larger than the 27 million already mentioned. For these reasons, we are opposed.

Mr. Chair, Members. Stephanie Watkins on behalf of the Association of California Life and Health Insurance Companies. In the interest of time, I will echo my colleagues comments. I'd also like to point out that we have reached out to CDI. I know they provided several sets of technical assistance and one of the goals, too, is to ensure that how CDI is interpreting the potential use of utilization management is consistent with the DMHC's position.

I know it's a little awkward because I know the intent of the author is slightly different from that. So as we continue to have these conversations, one thing to note is it would be harmful to the system if CDI had one interpretation that differed and so that was applied to the CDI regulated products versus another would be to the DMHC regulated products. So we are looking for clarification on that and also to the point on cost sharing.

To ensure that, we'd like to have some further discussions about the potential cost impact of some manipulation within the system. If somebody moved someone from a tier one to a tier three drug within the current policy year, we think that we would be frozen at the cost sharing of that initial script, which would certainly have a cost impact to the process. So for those reasons, we are opposed.

Thank you. Others in opposition?

John Winger on behalf of America's Health Insurance plans to just echo the comments of Cap and Eckler.

Great, thank you. Seeing no one else. We're bringing it back to the Committee, questions or comments? Dr. Weber?

Thank you, Senator Wiener. I am going to support this Bill to get it out of Committee. I do have some concerns, even as a provider with the ability to just kind of continue to prescribe a medication or go up or down or whatever, especially for a medication that is off label without having another eye set on it. So I'm going to keep looking at this Bill. But I think the foundation, your thought process behind it is just to allow it to continue to move.

Those with Colitis definitely have a very special, they're in a special category, but this also looks at all chronic conditions, not just Colitis. And so I am going to keep my eye, do a little bit more digging, do a little bit more research on this because it does make me a little bit uncomfortable, but I will support it today.

Anyone else? I plan to support the Bill today as well, and I would encourage continue working with the opposition. I did have a couple of questions, a couple of things that came up. I think it was from our witnesses concerned about adverse reactions. And I'm kind of puzzled by that because doctors prescribe medications. And my impression is it's really the responsibility of the Doctor to monitor adverse reactions, not the insurance. So can you explain that? Because I'm sorry, that feels like an overreach.

Yeah. Thank you. Dr. Wood. When we're looking at adverse reactions, you know, I think, you know, first and foremost we would say that providers plans, nobody is infallible. Right? So having an extra set of eyes like Dr. Weber mentioned, I think is always an important component to ensuring safety with our healthcare system. When we're talking about increases in dosage or changes in dosage form, I mean, we certainly understand and appreciate the context around the provider being the provider.

I think there are examples that we can point to around prescriptions that have been made in the past where dosages have been increased or prescribed in a way which can lead to adverse reactions. I think when we look at situations like the over prescription of opioids and the over utilization of opioids 10 to 15 years ago, about when that really started taking off, that, I think, for us is a type of example.

Where if dosages are increased in particular in that sort of scenario, or if a dosage form has changed again, when you're going from a pill form drug or pill form medication to an injectable medication, there does have some risk with that. So it's not to say that we think that we should be overriding the provider. That's not the case at all.

I think our perspective is that when our medical teams are reviewing those decisions, especially when it comes to medication, it's always helpful to have an extra set of eyes on that, ensuring that it's being prescribed and clinically appropriate.

Yeah, I can understand opioids. I'm not sure about medications for Crohn's disease being abused, but I take in what you're saying and understand that. I also heard you say you're concerned about the off-label use of medications. So I would hope you continue having discussions around those. I see the author wants to make a comment. Please go ahead.

No, well, first of all, on some of the technical issues and consistency between two departments, of course we'll continue to engage in that. I do want to note that painkillers are not part of this Bill. And if there's some language in the Bill that someone thinks they are included, I want to see that, because this is not like OxyContin, morphine Bill. That's not included in this Bill.

Also, you know, in terms of second set of eyes, this isn't just a situation where the insurance company says, "hey, we just want a note for you. We took a look at it and you might want to consider this," or "we think you missed that." This is about denying coverage, right? So it's not just a second set of eyes giving you more information, it's a second set of eyes overruling the doctor and saying, we're going to.

And I'll just give an example from my own experience, not in this context, but similar, when I first went onto a biologic 10 years ago, which was transformative for me, the initial response from the health plan was, you have to try and fail prednisone before you go on the biologic. Anyone who knows anything, and my doctor knew this, you don't try prednisone like regular, long-term prednisone as a first resort. That is like a last desperation kind of resort.

So the second set of eyes, which was denying coverage and ultimately it took quite some time to get that reversed. That second set of eyes were potentially harmful. Fortunately, I was not in an emergency situation, but that's happening on a regular basis and there are sometimes great experiences with health plans. Health plans are great, they're on it, it's not a problem. But you have these situations and ultimately this is focusing on the doctor knows the patient and that's what the focus of the Bill is.

Thank you. And I guess the other thing is about the health plan in some instances, are you not saying that this is your formulary and the PBM is the other set of eyes or is it actually the health plan?

Yeah, for utilization review. Generally speaking, the utilization review would be conducted by the health plan. Correct.

It's depending on what the relationship is. Sometimes the plan can contract with the PBM to do utilization management or a second set. I think one of the pieces is, and I think you mentioned it earlier, this Bill is much broader than Crohn's and Colitis. We're talking psychotropics for kids, things where certainly the increase in dosage without maybe someone else who might be looking to ensure that not only the best interest of the patient but the efficacy and safety. I mean, it's a partnership with providers and plans.

I mean, I know That's probably not a super popular opinion, but I think from our perspective, prior authorization or review provides a guidance and assistance. And I think the narrative, unfortunately is that it's always meant to be punitive. And I think the goal at times, and RX is a much faster process. Oftentimes it's a 24 and 72 hours process for prior authorization. I think the frustration is that if left unchecked, what then happens?

Who then, is the provider considered infallible with any dosage change for any chronic condition and what does that look like for the healthcare system?

Okay. All right, I appreciate that. Thank you. I guess no other comments. The Bill does enjoy do pass for recommendation. Would you like to close, Senator?

I respectfully ask for an aye vote.

Okay, well, we got a couple more members since the last Bill, so we're making progress. So go ahead. You've got ASB 339.

Thank you, Mr. Chair. First, I'd like to start by accepting the committee's amendment to remove the 100% physician rate reimbursement and instead use the contracted rate reimbursement. We appreciate the committee working with us. SB 339, which passed the Senate 40 to nothing, will resolve implementation issues with a previous bill that I authored in 2019, SB 159. SB 159 was the first law of its kind in the country.

And what it did was allow pharmacists to provide PrEP and PEP, incredibly powerful anti-HIV preventatives without a physician prescription, similar to birth control pills. For those who don't know, PrEP is a once-a-day pill, or now a periodic injection, that's recent, that comes exceptionally close to eliminating risk of HIV. It's almost impossible to contract HIV when you are on PrEP and taking it regularly. It is an absolute game-changer.

And if everyone at risk for HIV were taking PrEP, we would quickly eliminate new HIV infections, period. And then we could focus exclusively on making sure people living with HIV had the health care and the support that they need. And we would envision a future without HIV, would literally wipe out new infections. That's not happening. And there's a lack of access to HIV. And one of the pieces of that is that there are some obstacles for people. And we know that neighborhood pharmacies are providers that people interact with all the time. And so allowing pharmacists to administer provide PrEP like birth control or certain vaccinations will dramatically, we believe, increase access. And that access is particularly needed outside of urban centers and particularly in communities of color.

When we moved SB 159, we took a particular amendment based on dialogue with Senate B and P, and also the opponents to the bill limiting the ability of pharmacists to provide PrEP to only a 60-day supply every two years with the idea that you would then go see a physician after that. That has been a failure. It has not worked. And because for pharmacies, the idea of you're going to do 60 days, you're going to set up all this structure to do this, and you can only do the 60 days, it doesn't work. In addition, the pharmacies do not receive any insurance reimbursement for the time because they have to order labs and an HIV test and so forth. And in the meantime, other states have taken California's work without those problems.

Various other states have adopted what we adopted, but without the 60-day limitation and requiring insurance reimbursement, and they are succeeding. So this bill does two things. It removes the 60-day cap and it requires reimbursement subject to the amendment that we're accepting today. So I respectfully ask for an aye vote. And with me today testify are Dr. Maria Lopez, who is the president of Mission Wellness Pharmacy in San Francisco, and Craig Pulsipher, the legislative director of Equality California.

Hi, my name is Maria Lopez and I am a pharmacist. Mission Wellness is a community pharmacy in the Hispanic Latino Mission District in San Francisco, where we have experience establishing trust and serving diverse communities. I also serve as capacity building assistant consultant for HIV Prevention, which is funded by the CDC. Community pharmacies offer convenient longer hours than medical offices and are staffed by pharmacists who know the medications, maintain established relationships within the communities they serve, and have existing rapport. And this is key to adherence.

Based on published models, which Mission Wellness is one, pharmacists can safely and effectively provide PrEP and PEP, and that is why the CDC and federal partners support pharmacists furnishing PrEP and PEP. While SB 159 was the first bill of nation granting pharmacists authority, it is among the most restrictive. SB 339 will address these barriers for pharmacists. As the Senator pointed out, the 60-day supply is not working. It's not in line with the CDC guidelines, which recommends 90 days, and the one time supply every two years does nothing to increase PrEP access. Because there is a shortage of providers and patients cannot access ongoing PrEP, lack of reimbursement remains a major barrier for California pharmacists.

While our program in San Francisco has received limited support, the mere fact we cannot bill for services greatly hinders our ability to provide services for all patients who seek PrEP at our site, and we have had to turn patients away due to this barrier. To be clear, we have approached insurance companies about payment for services and have been repeatedly told they do not have a mechanism to pay us. Pharmacist authority to order labs for medication management and SB 339 outlines labs in accordance with CDC PrEP guidelines, and the National Pharmacy School Training Standards require pharmacy students to interpret labs and tests prior to graduation. Finally, this bill takes into account the varying levels of pharmacy settings. Some sites can provide one 9-day supply, while other sites can provide ongoing PrEP if they have laboratories set up and follow up. I respectfully request your support of this important public health bill to ensure patients have access to these life-saving medications. Thank you.

Good afternoon, Chair and members, Craig Pulsipher on behalf of Equality California, a proud co-sponsor. As you all well know, PrEP and PEP are essential tools to ending the HIV epidemic, and California has really been on the cutting edge in terms of expanding access. In 2019, we were proud to co-sponsor SB 159, which made California the first state in the nation to authorize PrEP and PEP to furnish PrEP and PEP without a physician's prescription. However, while this bill was a major step forward, over the past several years, pharmacists have reported significant barriers to implementing the bill, as Maria noted.

Last year, the California HIV AIDS Policy Research Centers surveyed over 900 California pharmacists and pharmacy students about challenges in implementing the bill and found that half of those surveyed said allocating staff time is difficult because the services are not reimbursed and nearly half believed that the 60-day limit is insufficient to make a successful referral to a primary care provider and ensure that patients remain on PrEP beyond the initial 60-day supply. As a result of these barriers, few pharmacies have implemented this component of the bill. According to the survey, only 11% of participants indicated that pharmacists were initiating PrEP and only 13% were providing PEP. SB 339 will remove these barriers and expand access to PrEP and PEP for Californians at risk for HIV.

To the questions that have been raised regarding patient safety and the need for involvement of a primary care physician would just note that under SB 159, all pharmacists are required to receive even more training beyond the training they have already received. And the bill includes protections to make sure that patients receive all of the testing and follow-up care that is recommended by the CDC. Pharmacists are also required to notify the patient's primary care physician if they have one.

And as further evidence that pharmacists are well equipped to provide these medications, numerous other states are now following California's lead, and many of them have passed laws without the restrictions that were included in SB 159. Last, I just want to note that even despite the incredible progress that has been made here in California, uptake of these medications continues to be extremely low. Only 25% of those who could benefit from PrEP are currently taking it. And uptake is particularly low in communities of color, particularly young people, and in more rural parts of the state. SB 339 will certainly not solve every issue that must be addressed to reach optimal PrEP uptake, but it is an important step in the right direction and I respectfully urge your aye vote.

Thank you very much. Others in support?

Chair and Members, Kathy Mossburg with the San Francisco AIDS Foundation, a proud co-sponsor, as well as APLA Health, also in support.

Thank you.

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

Thank you.

Kelly Brooks on behalf of the County Health Executives Association of California, here in support.

Thank you.

Claire Conlon on behalf of Biocom California, in support.

Thank you.

Mr. Chair and members, Paul Yoder on behalf of the City of West Hollywood and the City and County of San Francisco, in support. Thank you.

Thank you.

Rebecca Gonzales, National Association of Social Workers California Chapter, in support.

Thank you.

Good afternoon. Sandra Poole on behalf of Western Center on Law and Poverty, in support.

Thank you.

Rachel Mueller here with California Society of Health-System Pharmacists. I inadvertently mixed up my bills tonight. We are in support of 339 and weren't aware or providing anything for 238. So I apologize for my mix-up. Thank you.

No problem. Thank you.

Michelle Rivas, California Pharmacists Association, co-sponsor, in support.

Thank you.

Josh Tosney on behalf of Santa Clara County, in support.

Thank you.

Ryan Allain on behalf of the California Retailers Association, in support.

Thank you.

Rachel Bhagwat on behalf of ACLU California Action, in support.

Great. Thank you. And is there opposition to the bill?

No opposition to the bill. Oh, I'm sorry. Excuse me. I wasn't expecting you, but there are others lurking, so it's okay.

Respond to that.

It's okay. Usually, yeah. Anyway.

I'll take it as a compliment. Thank you, Mr. Chair. Ryan Spencer on behalf of the American College of OB/GYNs, District Nine, and the California Medical Association. I first like to emphasize CMA and ACOG's appreciation of the author's intent and a strong commitment to this issue. Expanding safe access to PrEP and PEP for individuals at the highest risk of HIV acquisition is incredibly important.

This is why ACOG supported its CMA colleagues in 2019 as they worked on SB 159 that authorized pharmacists to dispense a limited supply of PrEP and PEP for a limited time without a prescription. This compromised bill provided appropriate safeguards, which included appropriate follow-up care and a prescription to continue coverage of the medication. Unfortunately, SB 339 now removes these important patient protections, seemingly allowing a pharmacist continually dispense both PrEP and PEP in perpetuity unless appropriate follow-up is given, but it's unclear what qualified medical provider will provide that follow-up.

While pharmacists may be authorized to perform certain tests, their lack of medical training may not afford them the appropriate knowledge to interpret the results of such tests, such as what the results mean, and certainly not to treat the condition being tested. Without a follow-up visit with a qualified provider, significant medical issues, including those resulting from the drug, may go undetected and worsen over time.

We're asking for clarifying amendments to ensure the bill does not unduly expand the scope of pharmacists to test and treat conditions beyond their current scope to verify that patients furnished PEP and PrEP receive testing and follow-up care from a qualified health care provider which may or may not be a pharmacist within their scope of practice as authorized under California law. Until then, we must respectively oppose the bill and ask for your no vote. Thank you.

Thank you. Others in opposition?

Thank you, Mr. Chair and Members. I think you may have been expecting me. Jed Hampton with the California Association--Jed Hampton at the California Association of Health Plans. We have an opposed unless amended position on the bill. We believe that the amendments that are coming out of this Committee, I think, go a long way towards one of our concerns with the bill, so we're appreciative to the author and his staff and the sponsors for working with us.

We are still working around another potential amendment, around ensuring that helplines can use generic versions of specific drugs when appropriate. We're still working on that language and trying to come to an agreement on that, but we appreciate the author's openness and willingness to work with us, but for now, we are opposed unless amended. Thank you.

Thank you.

Steffanie Watkins on behalf of the Association of California Life & Health Insurance Companies, also with an opposed unless amended.

Great. Thank you.

We're going to all make a sitcom one day.

People change teams sometimes here. Dr. Weber.

Okay, thank you, Chair, for letting me jump in. I'm being summoned to another Committee, but with this bill, I do have--first of all, I want to thank you for bringing this bill forward. If what was previously done isn't working, then I do believe that's the time to go back and look and see how can we make things better, and we do want more people on this to decrease the prevalence of HIV. So thank you so much for that.

Today I will be abstaining from this vote, and I'm sorry, Ryan, I think you were probably talking about this, but I was talking with the sergeants. My concern is the lack of requirement for physicians to step in at any particular time. So you say in the bill, a pharmacist ensures that the patient receives testing and follow-up care. Follow-up care is just, do you have an appointment? It's not necessarily, did you go? Did you get the treatment?

And so when you're looking at all of these things that they're testing, as they should be for these medications, you have a patient who goes for this test positive for chlamydia. All right, we're going to make sure you have a follow-up with your doctor, but there's no way to know that you actually went and got treated for it or you have some abnormalities in your renal or liver function.

So I'm going to make sure you have an appointment, but I don't really have any documentation to say that you actually went and you're being evaluated for this. So the wording here, the language, is not strong enough to make sure that the patients are really being protected and their totality of their care is being taken care of. Just testing. I see something's wrong.

I'm going to make sure you have a fault appointment does not mean that when you come back, I'm checking to make sure that you actually went to the appointment that you got treated for whatever the issue was and now I can continue to give you this medication. So for that reason, I'm just going to stay off, and I hope that between now and time it hits the floor that we strengthen that language.

Yeah, I appreciate that, and I think there are certain situations--obviously, there's a situation if someone tests positive for HIV and then PrEP is no longer indicated. If someone has chlamydia, they obviously should get treated, and they don't have to go to a physician for that. You can go to an HIV clinic or an HIV counselor to get the med--they're under the supervision, but there are very efficient ways to be able to get that treatment, but you can continue receiving--taking PrEP even if you have untreated chlamydia.

We want you to get treated for it, of course, but that doesn't affect your eligibility for PrEP. In fact, we would not want someone to stop taking PrEP simply because they had another STI, but I do appreciate that feedback, particularly around abnormal labs, and we'll certainly go back and take a look at that.

Yeah, I would definitely appreciate that because, no, they shouldn't stop taking PrEP if they have chlamydia. They should potentially if they have, like, liver failure or kidney failure, but at the same time, that is one point where we can make sure that that particular individual is seeing a provider to not only treat it, but counsel them also on safe sex practices and do all of the follow-up care and the partner kind of screening to see who else needs to come in.

So I do think that there is a need, and I'm sure that you'll continue to think about it and work on it. I trust the people that are sitting next to you, and so I'll hold off today, but I am looking forward to supporting this on the floor. Thank you.

Thank you.

Very well, thank you. Ms. Waldron.

Thank you, Mr. Chair. I also want to thank the author for bringing this forward. A couple of years ago, not that long ago, I ran a bill that got passed and signed that recommended that the medical board include PrEP and PEP in the ongoing education of primary care physicians because it was found that about 33 percent of primary care physicians even knew of PrEP and PEP, and very few felt comfortable discussing the issues around it and HIV prevention in general.

Access. We talk about access all the time. Access is a huge issue for health in so many ways, especially in high-risk communities. This will help address some of those barriers to accessing and also adherence. It's one thing to access, but it's another thing to make sure that people are staying on it, and that's where the protection comes in. So trying to get into a primary care physician in a timely manner is very difficult.

We all know that sometimes it can be months trying to get in because of the shortage, workforce shortage, and it's far less costly to prevent a disease than to treat it. You know, there are some issues with it. I'm sure you'll continue to work on it, and I'll be supporting the bill. Thank you.

Thank you.

Ms. Boerner.

Thank you. I want to, again, echo my colleague's comments. I appreciate you bringing this forum. My sister is actually a health care journalist and has written extensively on PEP and PrEP, and I recently got the chance to see her and we were talking about it again and access and what California has done. So I appreciate that we need to make it even more available. I do share the concern that some people need to go to the doctor to get prescriptions.

We want to have this and make it available, but at some point, we need to be treated, right? And I equate it a little bit, and maybe it's not a good--I'm not very good at analogies, but I have an underactive thyroid. Every year I have to go in and I have to get tested. Are my TSH levels--I was going to say THC levels, but that's the wrong one--TSH levels. Correct. I'm blushing. I'm sorry. And are they okay, and do I need to change my dosage, right?

And so I think if there's a way to add a little bit more tightening language around that to ensure that people are getting care, that would be helpful. I will vote for it today because I think your opening line was about how do we reduce the prevalence of HIV, and as somebody who's 50 and known people who died of HIV and AIDS back in the 90s, this is amazing that we even have this medication, and I thank all the drug developers who've gone through all this stuff to ensure that my kids aren't growing up with the epidemic that we all grew up with. So thank you.

Thank you. Anyone else? Just another question, kind of a question for you. I noted in the background and that you mentioned that obviously this state was the first to move forward on this policy with the guardrails. Now we have other states that have been more successful. So probably not necessarily a question for you, but maybe more of a question for Mr. Spencer or others who can answer this. Okay, more successful in other states, but I'm not hearing options other than no for this particular bill.

So what's going on in other states and why are they more successful? Is this bill crafted the way it is in other states? And if it's being successful in other states, why the resistance to doing it this way?

I can't speak directly to what's happening in other states. What I can do is speak to what's our concern with this language having to do with the follow-up care. Aside from allowing pharmacists to be able to furnish PEP and PrEP over an extended period of time, we just want to make sure whoever is providing that follow-up care is qualified to do so, and that's really where--I'm not sure if that language exists in any other state. I haven't dove too deep into that.

As far as the--we've evolved our--we do have concerns about the lack of a prescription, but I think after our discussions with the author and the sponsor, I think we're really, primarily, really concerned about the follow-up care because that's really what matters here, to make sure that they're an appropriate candidate, continue to receive the PrEP and PEP, and so we want to make sure that--a pharmacist, frankly, may not be able to identify and surely not treat any condition they have and we believe the way the language reads now, it's just not clear that that wouldn't be the case and so we want that clarity.

That's where our position is on this particular bill at this moment. Is that helpful?

Kind of, but I'll let the author respond because I'm curious.

In terms of why--

Well, what's different in the other states? I mean, is your bill crafted after exactly what's going on in other states or is--

Well, those bills, as I understand, that were based on our original bill--

With fewer guardrails.

Right. They don't have the 60 day limitation as we understand it. So I can't guarantee if that's the only reason. I mean, these things are always complicated, but we know from the survey that was done that this is one of the--there were a number of restrictions that we put into the bill in 159, and we were very eager to look at the survey results on all of them and we ended up narrowing it down to these two things, that these were the two primary things: the 60 day limit and the lack of insurance reimbursement, and so that's where we focused the bill.

We could have included three or four other things, but we narrowed it down to what we view as the two major obstacles. As someone who, when I got PrEP, I got it from my physician and I was very lucky.

He was super with it and got it right away and didn't try to shame me or anything else. There are people who have had horrific experiences. It really runs the gamut from exceptional to horrific, but of course, in an ideal world, everyone sees a physician for a lot of things. We know that's not always how the world works. It is very hard. If someone is at risk, we don't want them to lapse--okay.

We took my 60 days, and now because I don't have a primary care or I couldn't get in to see my primary care, now I'm lapsing for 30 or 60 days and then the person gets HIV in the interim. Someone's taking PrEP because they are at risk, and so, yes, of course, if something goes wrong, whether the HIV test comes back positive or something's wrong with their liver, of course we want to get them in to see a doctor.

No one can force them to do that, but ultimately, this is a balance, and just like with birth control, people can have terrible side effects from birth control and there are some women who really have problems, but we don't ever force them to go see a doctor. You can get it from the pharmacist. Ideally, you would be seeing a physician, but we think it's so important for people to have easy access and not have those barriers that we've struck that balance, and that's what we're doing here as well.

Great. Thank you. Mr. Spencer.

Just real quick, and your question spawned a thought, when we initially had discussion, we did offer an option of an extended period beyond the 90 days. We're open to negotiation how long a pharmacist would be able to furnish the PEP and PrEP, but at some point, they would need to see a prescriber. That was initially the option that we offered, and now, right now, we're solely focused on the follow-up care, but we still do believe, and our hope would be that they would get a prescription eventually, but initially, we did offer the option too for an extended period of time.

Thank you. Well, as I said, thank you to everyone. As I said, the bill does--well, I didn't say that--it does enjoy a do pass recommendation, and if you want to hang tight, we actually have a quorum, so we could actually entertain motions. Yeah, I know; it's shocking. Would you like to close, Senator? Please, go ahead.

I respectfully ask for an aye vote, but it's always the magical time for the Chair.

It's very magical. You have no idea. Yes, you do, actually. Madam Secretary, please call the roll.

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

We have a quorum. We have a motion and a second on the bill. Motion is 'do pass as amended to Business and Professions.' Madam Secretary, please call the roll.

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

That's nine/zero. Your bill is out. We'll leave the roll open for others to add on. So, thank you. And you have one more bill.

Thank you. So, colleagues, I'm now presenting Senate Bill 770, which will establish tangible steps on a concrete timeline toward creating a system of guaranteed health care for all Californians that will provide better care at lower cost in the following ways. By directing the Secretary of HHS to pursue waiver discussions with the Federal Center for Medicare and Medicaid Services. To facilitate the creation of a unified healthcare financing system.

To require the secretary to establish a waiver development work group of diverse healthcare system stakeholders appointed by the Governor and leaders of the two houses, requiring the Secretary to provide quarterly reports to the chairs of both Health Committees on the status and outcome of waiver discussion with the federal government on the progress of the work group and requiring the Secretary to submit a complete set of recommendations regarding the elements to be included in a formal waiver application by no later than June 1st of 2024.

Colleagues, we know that the fragmentation and inequities of our current healthcare system, some of which we've heard about in the previous bill I just presented today, including varying health plan eligibility requirements to the continued lack of effective oversight of health plans, is harming California residents. These shortcomings result in severe and sometimes lethal gaps in medically necessary health coverage and disproportionately harm historically and systematically marginalized groups. In their final report, the Healthy California for All Commission summarizes the characteristics of a new unified financing system.

As all California residents being entitled to receive a standard package of health services, including long term care, support, and services. Entitlement will not vary by age, employment status, disability status, income, immigration status or other characteristics. And that distinctions among Medicare, Medi-Cal, employer sponsored insurance or individual market coverage will be eliminated within a system of unified financing.

The report estimates that universal coverage through a unified financing system will save 4000 or more lives annually in California, and finds that in the absence of a shift to unified financing, California will incur an additional $500 billion in medical costs over the next decade. SB 770, for the first time, will show the support of the Legislature for the work that the Healthy California Commission performed, along with clear steps to resolve the many policy and financing issues that the Commission left open.

The approach proposed by SB 770 will develop the required policy and financing details while building the political support necessary to achieve our shared goal: guaranteed health care for all Californians as soon as possible. Despite some claims from the opposition, we are committed to working with everyone interested in a better health care system to ensure we achieve this goal and make it a reality through a statutory pathway.

SB 770 is sponsored by the Healthy California Now Coalition, which is a huge coalition of labor, healthcare advocates, civil rights advocates, and others, and I respectfully ask for your aye vote. With me today to testify is Dr. Jeff Fraser, MD., and Ada Briceño, the co-President of Unite Here Local 11.

Please go ahead whenever you're ready.

Good afternoon, Chair Wood and Members of the Committee. My name is Jeff Fraser, and I am a retired neurologist. For 30 years, I practiced at Santa Clara Valley Medical Center, a large public hospital in Silicon Valley. I served as Department Chair for five of those years. I have seen the inequities and the follies of our current healthcare system, and I have personally dealt with the problem of physician burnout.

I believe that only a single payer, not-for-profit healthcare system with universal coverage will provide the necessary foundation for solving the burnout problem. SB 770 lays out a path to achieve the necessary reforms. Without such reforms, the burnout problem will only worsen and the physician shortage crisis will snowball. As Senator Wiener indicated, we have a highly fragmented healthcare system. As a result, doctors have to deal with billing policies and prior authorization procedures that are confusing, convoluted, and oftentimes just plain obstructive.

But more generally, and by the way, that is often cited as a major cause of burnout, but just more generally, more fundamentally, when encountering patients who have treatable medical conditions but who lack the means to get proper treatment, physicians experience what is now called profound moral injury. At our hospital, for example, people with seizure disorders would routinely show up in our emergency room having had a seizure because they had run out of their medications. Why had they run out of medications?

Well, for example, because having lost their job and their employer sponsored insurance, or having recently arrived from another county without insurance, they were unable to access our overwhelmed neurology clinic in a timely manner. A healthcare system that cannot reliably provide the simple service of refilling a life saving medication is absurd. But don't take my word for it. I urge anyone who feels my concerns are exaggerated to read the following two articles. Number one, "Doctors Aren't Burned Out From Overwork. We're Demoralized by Our Healthcare System," by Dr. Eric Reinhart, New York Times, February 5, 2023.

And number two, "The Moral Crisis of America's Doctors: The corporatization of health care has changed the practice of medicine, causing many physicians to feel alienated from their work," By e all press, New York Times, June 15, 2023. SB 770 gives doctors hope that California's state policymakers will address their plight, and most importantly, the plight of their patients. SB 770 would help restore the quality, the dignity, and the core mission of the practice of medicine, so that doctors will be there when we need them. Thank you.

Thank you.

Good afternoon, Chair Wood, and also Members of the Committee. My name is Ada Briceño and I'm co-President of Unite Here Local 11. I'm also here speaking on behalf of the Democratic Party of Orange County. I've been a union organizer for the past 32 years, and in that time, I have watched health care really eat up at the cost more and more of the salaries and the income of working families. Thousands of hotel workers in our jurisdiction are about to strike, if not this week, the upcoming week.

And it's been driven by the fact that wages haven't kept up with the cost of living. Health care costs are a huge part of what's driving the affordability crisis. If premiums had just gone up at the rate of inflation over the last 20 years, Los Angeles and Orange County housekeepers and dishwashers would have well received over a hundred thousand or more each in their pockets, money that would have gone a long way to guaranteeing housing security today. I'm here to appeal to you to get the ball rolling on fixing this crisis. My union and the broad coalition is convinced that a path to doing that is by creating a unified financing system for health care.

That kind of system would make sure that every resident could count on health care when they need it, regardless of what kind of job they have or how much money they make. It would save our state hundreds of billions of dollars over the upcoming decade, and it would save people's lives as you heard 4,000 a year, and that's according to the Healthy California for All Commission. But even if you don't agree that a Medicare-for-all like system is the way forward, I hope that you can agree that we need to get the critical information this Legislature needs to make an informed decision.

There are hundreds of decision points that will go into deciding whether and how California designs a unified financing system. We need clarity as to what the federal government is prepared to go along with so this Legislature can draft a Bill that has the highest chance of success. SB 770 holds the state accountable to following through the Healthy California for All Commission's recommendations. It directs the Administration to clarify with the federal government what might be possible and at what cost. And it does that on a timeline that lets legislators act with urgency and the care that this crisis demands. Please pass 770. Thank you.

Thank you. Others in support of SB 770? Just your name and organization if you represent one, please.

Bruce McClain. North State Medicare 4 All. I urge your support.

Thank you.

Thomas Brandon, California Conference of Machinists. I urge your support. Thank you.

Thank you.

Sal Rosselli, National Union of Healthcare Workers, strongly urge your support.

Thank you.

Forest Harlan, the Butte County Health Care Coalition, in strong support.

Thank you.

California. I'm sorry. Kathy Fatinos, California Alliance for Retired Americans. We urge your strong support.

Thank you.

Amy Hines-Shaikh with Wild Cat Consulting representing Unite Here Local 11 in strong support. Thank you.

Thank you.

Cindy Young, Vice President, California Alliance for Retired Americans. We urge your support.

Thank you.

Hello. Eric Limas from the Inland Empire. Here for Inland Equity Partnership and Inland Equity Community Land Trust.

Thank you.

Good afternoon. Linda Nguy with Western Center on Law and Poverty in support, along with California Pan Ethnic Health Network.

Thank you.

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

Thank you.

Henry Abrons, Physicians for National Health Program, California Chapter, in strong support.

Thank you.

Devra Dallman, Health Care for All California in very strong support.

Thank you.

Daniel Hodges, co-founder of Health Care for All California, strong support.

Thank you.

Mark Dahlman, Health Care for All California, in support.

Thank you.

Robert Copeland, California Alliance for Retired Americans in strong support.

Thank you.

Good afternoon. Shane Gusman, on behalf of Unite Here International Union and the Teamsters, in support.

Thank you.

Good afternoon. Tiyesha Watts with the California Academy of Family Physicians in support based on the amendments we worked on with the author's office. Thank you.

Thank you.

Beth Malinowski with SEIU California in support.

Thank you.

Carolyn Bowden with Healthy California Now in strong support, proud co sponsor.

Thank you.

Good afternoon, Irene Kao with Courage California in strong support.

Thank you.

Stephen Vernon, Therapists for Single Payer and Physicians for National Health Program California, in severe dismay of the dissension that's around this issue. In strong support.

Thank you.

Craig Pulsipher on behalf of Equality California in support.

Thank you. Seeing no one else. We have a motion by Ms. Boerner, a second by Ms. Aguiar-Curry. Is there opposition to the Bill? Reminder, we have two witnesses to testify.

Yes. Chair Wood, we had a request for you. If we could have myself from CNA, Black Lives Matter California, and Health Care for All split our time for two minutes, we would very much appreciate it. If it's okay with you.

We will honor that in the future. I'd appreciate it if you'd let us know you're bringing three witnesses. Thank you.

Yes.

So, two minutes each.

Thank you, Chair Wood and Committee Members. I'm Carmen Comsti, lead regulatory policy specialist with the California Nurses Association, proudly representing over 100,000 registered nurses throughout the state. CNA has for decades championed guaranteed health care for all through a single payer system. And we recognize Senator Wiener's continued support for CalCare. However, we strongly oppose SB 770 because this Bill would unnecessarily delay California from achieving this goal.

As a women of color led union, CNA intimately knows that delays in ending the profit motive in healthcare will cost us the lives and the health of black, brown, and other marginalized and income insecure communities. This Bill unnecessarily would task a new, informal work group to duplicate the work of the Healthy California for All Commission, which I proudly served on with Dr. Wood for two and a half years.

The Commission analyzed the issues of unified financing, including on federal waivers, and we spent millions of taxpayer dollars in the process. The final Commission report provides everything you need to take decisive legislative action on guaranteed health care for all. Concerningly, however, this Bill would restructure our healthcare system through an unaccountable work group and few tie waiver discussions with the federal government. Federal waiver law is clear. California must first enact a policy Bill like single payer before federal HHS can lawfully sit at the negotiating table.

SB 770 is not a single payer Bill. It is a unified financing Bill. The Commission was clear that unified financing could mean a multipayer system with a role for health insurance where insurers and other profit driven middlemen continue to squeeze wealth from our health. Continued delays is unacceptable to the nurses of CNA. We respectfully urge a no vote.

I do want to apologize. I did not realize that my staff just informed me of something here. So my apologies. So you have two more minutes each. So go ahead.

Hi, I'm Sheila Bates. I'm the policy lead with Black Lives Matter California, a coalition of chapters across the state, which is a part of our larger organization, Black Lives Matter Grassroots. We work to end state sanctioned violence against black people in all of its forms: physical, economic, social, and political. Black Lives Matter California supports single payer health care, a necessary policy that is long overdue, that can transform our state and literally save lives.

Black Lives Matter believes in tearing down systems of harm while building systems of care that absolutely include single payer health care. Accessible, taxpayer-funded, comprehensive, culturally appropriate health care, as laid out in CalCare, is a form of public safety. Due to our positioning, we are in strong opposition of SB 770, a Bill that could not only derail California's single payer health care efforts, but single payer health care efforts throughout the country.

Black Lives Matter California, its leadership, membership, and the larger black community have experienced and or seen the very real, devastating and deadly effects of medical apartheid. This is not only clear through anecdotal evidence as demonstrated in qualitative data, which are our stories, but also in quantitative data that tells us that black women are three to five times more likely to die in childbirth than white women, or that black infants are 2.3 times more likely to die in their first year than white infants, and several other health disparities clearly documented in the data as a result of social determinants of health.

We know that a true single payer health care Bill such as CalCare is meaningful redress to medical apartheid that continues to steal lives and negatively impact the health of black Californians. We see SB 770 as a barrier to real solutions. We don't need more studies. The data is there. We don't need more working groups as proposed by SB 770. We need meaningful action now. We must stop SB 770 so we can advance and pass a true single payer health care Bill.

We urge the Members of the Assembly Health Committee to speak up and advocate for residents who are counting on their vote so that we can get to the meaningful, life saving, and life affirming work of passing CalCare a comprehensive single payer health care Bill. We can no longer wait. Too many lives have been impacted and continue to hang in the balance.

Good evening, Assembly Members. My name is Cheng-Sim Lim. I'm an immigrant and a two time cancer survivor. Having cancer opened my eyes to the gross inequities of the health insurance system, and that has turned me into a single payer activist since 2016. Today, I represent Healthcare for US and Asian Pacific Islanders for CalCare to say we strongly oppose SB 770 and call on this Committee to vote it down. I'm not a lobbyist, a consultant, or even a paid staffer at a nonprofit union.

Single payer activists like me are unpaid volunteers. We are not interested in political games. We have no agenda other than to have California enact single payer. Please hear us when we say SB 770 is not a single payer Bill and is, in fact, detrimental to the real single payer Bill, CalCare. Everything about SB 770 is disingenuous. Its sponsor has claimed that the Bill is complementary to single payer when the Bill actually proposes more time wasting on waiver discussions that are not even specific to single payer.

The bill's timetable gives cover to legislators to say they cannot pass CalCare in 2024 because they have to wait for SB 770 mandated reports to come in next summer or possibly later. But most disturbingly, with its unified financing language, SB 770, if passed, will set the stage for California to codify a multipayer system where insurance company intermediaries, HMOs and ACOs, will administer healthcare using public funds. This is absolutely antithetical to single payer and defeats the entire purpose of healthcare reform.

I call on you, Assembly Members, to do what's right morally, financially, and, yes, politically. You have the power today, right now, to save lives and money. Vote no on SB 770, then act to pass CalCare. Thank you.

Okay, thank you. I am going to give another witness an opportunity to speak in opposition. We had three witnesses representing the same group, correct? Yes?

No.

Well, she said, I'm here to support CalCare. You here to support CalCare. That's what I thought I heard from the third.

No, I'm here on behalf of the California Nurses Association.

Ok. Regardless, I'm going to give another witness two minutes, and then I'm going to give Mr. Wiener, Senator Wiener, an additional two minutes if he would like. Please go ahead.

For opposition?

For opposition, correct.

Thank you. I appreciate the accommodation. Nick Louizos on behalf of the California Association of Health Plans. I do appreciate the accommodation since our opposition is coming at this Bill from a completely different angle. We oppose the Bill because it requires the state to petition the federal government for a waiver. It's authority that California doesn't require or need to basically change the system in a way that Californians don't want.

Basically, SB 770 is the first step, from our perspective, toward a government run healthcare system, which would not only eliminate Medicare as we know it, but the medi-Cal program as well. It would prohibit all private coverage and force every Californian into an untested new health system with no ability to opt out. Single payer in California has been analyzed in the past. It's going to cost over $500 billion a year, requiring large tax increases on individuals, employers, and small businesses.

And it doesn't do anything to address the workforce shortages that we've seen in healthcare, or it will do nothing to keep doctors and hospitals in the system. The Bill also asked the Legislature to endorse the Healthy California for All Commission report, a long document, but one that doesn't answer fundamental policy questions. Committee Members should ask themselves whether they are on board with that endorsement of this report, particularly if you haven't been briefed on its contents.

California has made incredible progress in expanding access to affordable coverage since the passage of the Affordable Care Act. And indeed, the budget that was passed today includes significant investments in access to health care and lowering of enrollees out of pocket costs. So we are making great strides in California. Studies continue to show that Californians are largely satisfied with the health care that they receive in California and they do not support this transition to the healthcare system. So we're opposed for those reasons. And thank you again for your indulgence.

Great. Thank you. So, others in opposition to the Bill?

Stefanie Watkins, on behalf of the Association of California Life and Health Insurance Companies also opposed.

Thank you.

Faith Borges on behalf of California Agents and Health Insurance Professionals. Opposed for the reasons stated by Mr. Louizos.

Thank you. Just your name. No banners, please. We typically don't allow banners in the room, so I'm not sure where you got the impression you could do that, but please, no banners. Just your name and organization if you represent one.

Isaac Lieberman. I'm a county RN. I oppose SB 770 because it's not.

Just your name and organization. Please respect our process, please. Just your name and organization.

Isaac Lieberman. EPAA.

Got it. Thank you.

Carol Federa, retired pediatric occupational therapy, Health Care for Us. Strongly opposed.

Thank you.

Nyabingi Kuti, LA Harm Reduction Network. Single pair now. No more delays.

Dolores Flanagan, California Nurses Association. Opposed.

Thank you.

Kathleen Hernandez, MLK Coalition of Greater Los Angeles. Strongly opposed.

Thank you.

Mike Lim, on behalf of Asian Pacific Islanders for CalCare, opposed.

Thank you.

Maggie Vasquezeno Harriet Tubman Center for Social Justice in Los Angeles strongly oppose SB 770.

Thank you.

John Thompson Parker, coordinator of Harriet Tubman Center for Social Justice. I got a stroke two months ago.

RN. I represent Wellstone Progressive Democrats of Sacramento and Healthcare Committee of DSA, Sacramento.

Thank you.

Sorry, I'm having a little problem with my ear. I have tinnitus, so, Betty Doumas-Toto down here from Los Angeles. I'm with Medicare for All Everywhere. I'm an elected Los Angeles County Democratic County committee member, and I strongly oppose this. No more delays.

Thank you.

Jeanine Rohn, elected delegate to the L.A. County Democratic Party and the California Democratic Party, Assembly District 52, which includes East L.A. and Southern Vice Chair of the Senior Caucus of the California Democratic Party and a true single-payer activist. I strongly oppose.

Thank you.

Kayla Westergard-Dobson representing Hollywood4CalCare. Strongly opposed.

Thank you.

Christopher Carlson, Hollywood4CalCare, opposed.

Thank you.

Sara Colegrove, registered nurse here with California Nurses Association. Strongly oppose.

Thank you.

Sergey Force representing CalRedBerets, which is a California Chapter for Red Berets for Medicare for All. Strongly opposed.

Thank you.

Rachel Cohen Cepeda, registered nurse with California Nurses Association. Opposed.

Thank you.

Paul Newman from HC4US. Strongly opposed.

Thank you.

Karen Boxley-Cottman, RN, strongly opposed, California Nurses Association.

Thank you.

Good afternoon. I'm Alma Caravarin. I am the community organizer for the Immigrant Equity Program with Placer People of Faith Together and I am also an independent health care interpreter and strongly oppose SB 770.

Thank you.

Gina Viola, White People 4 Black Lives and a business owner, and I'm strongly and opposed.

Okay, thank you.

Mawata Kamara, Public Sector Nurse with the California Nurses Association, strongly opposing.

Thank you.

Wanda Duffy from Health Care For Us, MFT associated. Oppose.

Thank you.

Paul Gabiana, Chief Nurse Rep, Bakersfield, California Nurse Association. I oppose.

Thank you.

Shirley Toy, representing Wellstone Democratic Club, Sacramento DSA Healthcare Committee, API for CalCare and CNA Member.

Thank you.

Strongly opposed.

Maureen Cruz, former Department of Health Services, Los Angeles County, RN, current Co-Chair of Health Care for Us and Member of DSA-LA Healthcare Justice Committee. Strongly oppose.

Thank you.

Hello. Stephanie Terrazas, union worker and delegate for Assembly District 56. My constituents strongly oppose SB 770. Thank you.

Thank you.

Martha Huerta, AD 56 delegate and retired deputy labor commissioner for the State of California. Strongly opposed.

Thank you.

Dennis Hersendez, elected delegate to the Los Angeles County Democratic Party and appointed member to the California Democratic Party. Also a member of Health Care For Us. Strongly opposed.

Thank you.

Anthony Mercado, constituent AD 56. I strongly oppose. Go CalCare.

Thank you.

Jennifer Portillo, delegate representative on behalf of AD 56 and the National Nurses Association in conjunction with a California Nurses Association, strongly opposed on behalf of our constituents.

Thank you.

Holly Khan, registered nurse, CNA, strongly opposed.

Thank you.

Waku Spurlock, registered nurse, CNA, strongly opposed.

Thank you.

And also as a navy veteran, strongly oppose.

Thank you.

Michael Williams from Black Lives Matter, Los Angeles, a part of Black Lives Matter, California, and I strongly oppose and we strongly oppose.

Okay, thank you. Anyone else? Did you want additional time, Mr. Senator Wiener?

I don't think we do.

Okay. All right, thank you. Bring it back to the Committee. Questions or comments from the Committee? Dr. Weber and then Mr. McCarty.

Thank you, Senator Wiener, for this bill, and thank you for all those who spoke, and I do apologize that I had to step out to another Committee so I wasn't able to hear everything, but my question is, I've heard talk about this bill delaying or preventing the implementation of a single-payer for five years. Can you show me--just yes or no--can you show me where in the text it says that or it mandates that?

It doesn't. My understanding is that Assembly Member Kalra has a spot bill right now, that presumably he'll put the full bill into print, I assume early January, and I appreciate the opposition acknowledging I've co-authored every single-payer bill that's been introduced since I joined the Legislature. I know he's planning to do that. This bill requires that the report come back very quickly. It's June 1st of next year, so in the middle of the legislative session next year.

I think the opposition has pointed to the fact that it sunsets in 2028 because the way that sunsets work around working groups, it tends to be four years or whatever the typical rule is. That's the only reason that's there. The deadline for them to report back on what the scope of a waiver could look like is June 1st of next year, and so that does not in any way impede other efforts from moving forward.

Yeah, thank you for that. I've read the bill. I've read the analysis. I could not find anywhere in the bill or the analysis where it states that passage of this would prevent the implementation of a single care health care system. So maybe if someone in the opposition could tell me where it mandates that in the bill, and I'm just asking because I know a lot of the people who spoke up today kind of referenced that this would delay it or prevent it.

I think I read somewhere else that in the opposition here in the analysis that that was one of the concerns, but I just don't see that mandated in the bill, so can you show me where that is?

Sure, Dr. Weber, and it's a good question to raise. I think one of the main concerns is that this bill would task a work group to consider federal waivers. So if we are discussing, as a state with CalHHS, federal waivers on the timeline, the first report is due in June of next year, and there are quarterly reports thereafter until 2028. If the federal government and CalHHS are having discussions on federal waivers, this will stall the Legislature having to discuss single-payer, which would require federal waivers.

And we know, as we talked about, the law on federal waivers requires that when you consolidate multiple federal waivers together, the federal law requires that a bill is passed. So we're essentially putting it backwards with SB 770 where there are discussions that are informal with CalHHS and federal HHS, so it's really fundamentally very confusing because how can our state have discussions with the federal government that really don't have any final component to it when they have informal discussions?

We're never going to get to single-payer because in perpetuity we'll have informal discussions until when? I think that's really fundamentally one of the biggest issues. I don't know if other folks want to talk about the political ramifications that we also see.

Mr. Chair, that's just not what the bill does.

Right, I didn't, I didn't--

I don't want to get in--a direct answer to her question. A question was, 'where in the bill does it say that?' So that was what she was seeking as her answer, I believe. I don't want to put words into Dr. Weber's mouth because--

No, I--

But that was the question, I believe.

Yeah, I'm looking for it because I've heard that that's what this bill does, but I just don't see that in the language, nor do I see that in the analysis, and when I've spoken with some of the people who are looking at this bill, they couldn't see it either, so I'm actually wondering, where is it, because I don't want to do something that has a--something in my face that says it's going to happen, but I don't see it. So that's why I'm asking, where in the bill does it mandate that if this is passed, we can't have single-payer until 2028?

I think in my testimony I said that the bill's timetable gives cover to legislators to say that they cannot pass CalCare in 2024 because they have to wait for the mandated reports to come in in the summer, in June, and as I understand it, the CalCare bill, which Assembly Member Ash Kalra is going to introduce next year, has to pass out of its House of origin, which is the Assembly, by late May.

It's actually January.

I'm sorry?

It's in January.

So January, and then it has to pass through the Assembly in May, correct?

In January, it has to pass out of here. A two year bill has to pass out of this House in January.

We understand it'll be not a two year bill. It'll be a---

If he's introducing a whole new bill, I don't know. He has a bill that, as Senator Wiener said, he has a bill he's introduced. He could move that in January. If not, then he goes to the normal process. So I have no idea what Mr. Kalra has planned.

Our understanding is that it would be a new bill that's introduced, so--

We don't know that.

Yeah. With that understanding, again, we understand the legislative calendar is such that it has to pass out of the Assembly by May, but what SB 770 does is it says that it has to have a report June 1st. That's the main report is June 1st.

So what we are saying is that that gives ready cover to legislators to say, we can't pass health care out of the Assembly in May because we have to wait for the SB 770 mandate report in June, and then we don't know what the process could be. It could be that the work group that's proposed by SB 770 will ask for extensions, right? So those extensions could extend past that June 1st date anyway. So, there are all these questions that are not answered in the bill.

It's a very vague bill, and I think to answer another part of what you said, that how is this bill not single-payer, I'd like to draw your attention to actually specific language in the bill.

No, my question isn't 'how is this bill not single-payer?' My question is, 'how does this bill prevent us from voting on single-payer' because that's what I'm hearing. So it sounds like the date, June 1st, that's not a mandated date. It says no later, so they can't go past it. So if they have--Senator Wiener, if they have it by May 1st, could they?

Yes.

February 1st?

Yeah. That's the latest date and that's a very short turnaround, right? If this bill were a delay tactic, it would have said, 'turn in your report in five years.' The fact that the bill goes into effect January 1st, and five months later, they're expected to turn in their report--shows that this is not a delay tactic; we're not trying to slow anything down. Mr. Kalra will do what he's going to do, and I have enormous respect for him, and this does not change that.

Thank you. I just have one more question because, like I said, I could not be here. I was in another Committee. The waivers, can we fully implement CalCare without the federal waiver? I don't know. Either Committee staff or...

Well, and again, I don't want to speak for Assembly Member Kalra and what he may or may not put in his bill, but the typical understanding is that we would need a federal waiver because these various funding streams are--a lot of them are controlled or governed by federal law, so we would need a federal waiver. I don't think there's a lot of disagreement about that. I think the analysis does a very good job, very thorough job, of describing who could grant different waivers. And for some sources, like Medicaid, there's an argument that it could be done administratively.

For others, like Medicare, there's a much stronger argument that it may require an act of Congress. And so it's complicated, which is one of the reasons why I'm not suggesting there have been no discussions, but this is sort of a tangible step to figure out what the scope of a waiver would look like.

The bill does not require submitting the waiver, and that's why this argument that, 'well, you can't submit a waiver until you passed a policy bill,' this bill doesn't require the submission of the waiver. It requires work to craft what the scope of the waiver would look like, having those informal conversations with the federal government to figure that out.

Okay, so it's not requiring that we actually apply or get a waiver. It's just figuring out, do we need one and what the process is to get it?

And what the scope of the waiver would be, what a waiver would look like. But it does not require the filing or the submission or making of the waiver request.

Okay. Thank you.

Mr. McCarty.

Yeah, thank you. Just following up what Dr. Weber here had. So clearly the bill doesn't say that by implementing this, CalCare would not be able to go forward. They're just saying the impact if this passed, and so I don't think that is quite accurate, as you allude to, but the big picture here is that I asked to be on this Committee for the speaker six years ago because the price of health care is just ridiculous. Too many people get left behind.

It's the number one reason why people file for bankruptcy. It's the reason why school districts and cities are fighting with their employees to pay living wage and salaries. It's health care costs many times. Small businesses can't pay the increasing premium. So doing nothing, this will all fall apart. It's a house of cards if you look at the ever increasing cost of premiums, and so, I supported the single-payer first bill like you did. I think it was, Senator Lara's, that first bill.

And then we've had a second bill by Assembly Member Kalra, which I was a joint author like you as well, and there's a third one, which I'm a joint author now for a third time, and you right now are waiting to see it fully in print. So this is a bit complicated, and I'm torn because, you know, we had a colleague, one of our friends here, Lorena Gonzalez; she had this sign in her wall which her and I believe in this: is the most amount of good for the most amount of people.

That's what I try to do in this job. And we've been increasing subsidies for Affordable Care Act, Obamacare. We've increased through Dr. Arambula's leadership and this Committee as well, Dr. Wood, in the budget to cover people that aren't covered by that, people that are undocumented, and people still slip through their cracks. So I still believe that we should have universal health care at one time to focus on efficiencies.

I think too much money leaks out of the system, doesn't go to protecting people, but it leads us to the key question which I think you're asking us is the perfect versus the good. We don't want the perfect to be the enemy of the good, and that's what I think you're trying to do because in reality, I don't necessarily see a path for the other bill. I don't see--the votes fall dramatically short. My name's there. I'll take the heat for it.

My name there. I support it. I stand by it, but it's nowhere close, and so in the meantime, are we going to be purists or try to get more? And that's what I think that this bill is trying to do, and so I don't think they are mutually exclusive.

And I want to have you, Senator Wiener, another chance to kind of walk through--walk through--help us in more plain English, how these are not mutually exclusive and how these things potentially can be on two tracks and what these waivers mean. Can one waiver be used for the other potential policy choice where you have to focus on the federal waiver?

Well, as the opposition--and thank you for that, Assembly Member--as the opposition noted, if CalCare passes, then at that point, California will go to the federal government and make the waiver application, and CNA is, of course, the sponsor of the CalCare bill, and if that's how it happens--pass the bill, get signed into law, present the waiver application--the work here to have those discussions with the federal government to figure out the scope and the structure of that waiver will be helpful. And so it dovetails.

And I want to also just stress this is democracy, and people who are sometimes parts of coalitions, sometimes coalitions have internal disagreements. The folks here on both sides of this bill have historically worked very, very closely together on expanding health care access and moving towards truly universal health care, and there's been this disagreement now, and I hope in the future that that rift heals, but we all want the same result.

We want everyone to have truly global, universal access to health care without having this fragmentation and having the unification, and so that's how I see it. That's why I think the bills are complementary.

Yeah, I concur, and I think it's an important point you make. This is a middle approach. There are some people who want more, who are opposed, and there's clearly people--we heard opposition who don't want any of these policies, don't want CalCare, don't want this. But I don't know by doing nothing, we're going to make any more progress than we're currently at, so sometimes we have to make tough choices. This isn't voting down, you know, what they're about.

It's doing something now to move California forward and expand health care for our residents. So I know there's been a motion to second. I support your bill. Thank you, Senator Wiener.

Thank you.

Anyone else? Mr. Rodriguez.

Yeah, I want to thank the Senator for bringing this forward. Obviously, we've been discussing this for the last couple of years now, right? So just want to talk a little bit regarding the waivers. I'm kind of looking through the language of your bill as well, but maybe as we look for the waivers, do you think we'll be confident we'll get the waivers for one?

CalCare has, as any difficult bill that is transformational, sometimes you have a long journey, and so obviously the journey through this Legislature is not an easy one. We've seen that in the past, although single-payer did pass the Legislature a number of years ago and was vetoed. So it's possible, but that's a tough road through the Legislature. That is, I think, doable. And then working with the federal government; these are all challenging processes that are going to take a lot of work and focus.

Can I guarantee a waiver will be granted? No. I don't think anyone can guarantee that. We don't know. It depends on who the Administration is. It depends on if an act of Congress is required. Obviously, that's its own situation, and so that's why the work we're doing with this bill I think will be helpful in figuring out what the options are and what the most effective, most likely to succeed structure is.

Then with that, you spoke regarding the process at the federal level. Obviously would also look at if we have a different administration, Republican administration, how would that look for one, and for two, if we were to get a different administration, could that new administration pull the waivers back? Once they've been given, right?

It depends because, again, if an act of Congress is required for part of the waiver, obviously Administration cannot revoke that without a subsequent act of Congress. So if an act of Congress is required, that is clearly more cemented into law. In terms of administratively, yes, different administrations, and this is something that happens. Different administrations can take different positions, but that's true today. There are health care waivers that are granted by the federal government today that can be revoked by a subsequent administration.

So I think clearly as we go through this process, if CalCare is able to move through the Legislature, we're going to have to be very mindful about how we structure things to try to protect California, and I'm very confident that our Administration and advocates are going to be extremely careful and methodical about making sure that we're protecting Californians.

Yeah, and then the last one is obviously the cost, right? Because somebody has to pay for this no matter what, right? And when we have obviously the bad budget years like we're experiencing now, how that we take that into effect, right, that there is funding no matter what, right? Because it has to get paid for one way or another.

So it's something that one of the biggest issues for me as well is the cost, especially when our state is in a position like we are now with money is tight and we look to cut positions, to cut things. How does all of this--it's a very complicated issue, right? There's a lot of moving parts. We can't just say it's here because we got to see how everything else falls into place. So that was just another concern I had regarding the cost and how that works out.

Yeah, I mean, the good thing is, and what makes me proud to be part of this Legislature, we're in a bad budget the year this year, and we are really protecting access to health care. We're shoring up our hospitals. We're actually improving payments for Medi-Cal, which is long overdue, and we're doing that in a bad budget year because California is so committed to health care, and we've also stabilized our finances dramatically since the Great Recession, which was a disaster.

You know, and I think if you look at what we're talking about with single-payer, unified financing, there are enormous opportunities to make costs more efficient. The current system is not an efficient system, in terms of cost. It's the opposite.

Thank you.

Anyone else? Seeing no one, it's up to me. We've had a testimony already, so thank you. So I want to thank you, Senator Wiener, for introducing the bill today. You know, Dr. Arambula and I are veterans of this discussion. Were it not for the work that we did, there wouldn't have been a Healthy California for All Commission. It was our idea, and Governor Brown actually took it and put it in the budget and made it a reality and it was started by Governor Newsom.

So we're well familiar with the Healthy California for All Commission, and then, so I'm very familiar with the work. I sat on the Commission and the recommendations of the Commission on how we go forward to establish a framework for a unified health care financing system. That was how I understood it. Now, others may disagree, but that is how I understood it. The formal process and the timeline that your bill establishes creates a clear pathway to achieve unified financing. That's, I believe, what you're after from my interpretation.

It's also consistent with the Commission's recommendation to develop a full proposal on unified financing, and the June 1st deadline to report to the Legislature on elements necessary for a formal waiver application is critical for the Administration to meet its obligations to accomplish and deliver unified health care financing for all Californians. So I plan to support your bill today. With that, would you like to close?

I think we've had a great discussion, and I respectfully ask for an aye vote.

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

Wood? Aye. Wood, aye. Waldron? No. Waldron, no. Aguiar-Curry? Aye. Aguiar-Curry, aye. Arambula? Aye. Arambula, aye. Boerner? Aye. Boerner, aye. Wendy Carrillo? Flora? Vince Fong? Maienschein? McCarty? Aye. McCarty, aye. Joe Patterson? Rodriguez? Aye. Rodriguez, aye. Santiago? Villapudua? Aye. Villapudua, aye. Weber? Aye. Weber, aye.

Your bill has eight votes; is out of Committee. We'll leave the roll open for others to add on.

Thank you very much, Colleagues, and thank you for all the bills today. Appreciate it.

We while we're waiting for the I know Senator Eggman is going to come up next, and maybe I'll have Madam Secretary, please call the well, do you have a motion on the consent calendar? A chorus of movement there. So. Ms. Aguirre curry Mr. Mccarty will give them credit this time. Motion for consent calendar, which is item number 9, SB 45 Roth with amendments. Item number 10, SB 344. Senator Rubio. Madam Secretary, please call the roll on the consent calendar. Wood aye.

Wood aye. Waldron. Waldron. Aye agar curry. Agar Curry. Aye Arambula. Rambula ayeburner. Wendy Carrio Flora. Vince Wong. Vince Wong. Aye Maienschein Mccarty Mccarty. Aye Joe Patterson. Rodriguez Rodriguez. Aye Santiago Via Poudois. Via Poudois. Aye Weber Weber aye.

That's 9 - 0. That Bill is out. We'll leave the roll open for others to add on Senator Eggman. And please, if you have discussions, please take them outside. If you're not, thank you. Give our respect to Senator Eggman. Please.

Thank you very much, Mr. Chair and Members. I'm so happy to be here in front of you today to talk about SB 43, which is the latest in a long line of bills on focusing on grave disability. As you all know, grave disability was defined in our LPs laws in 1967. And just to add, because there's been some conversation that we're including subs abuse, that chronic alcoholism was included in the original legislation and has been a part of it the entire time.

It refers to also items that are found to meet the criteria in the DSM, which is where you find subs abuse and alcoholism and severe and persistent mental health issues. And, of course, we were all very happy in 1967. Many of you weren't alive yet, but those that were, we thought it was going to be a grand redo of things. And while the impetus was good, the implementation was horrible.

And we have seen over the years, without a lot of investment in our mental health system, we have seen those who are the most ill continue to suffer on our streets in ways that is disturbing to, I think, everybody who walks around and sees it. It is not compassionate, it is not progressive, it is not humane to allow people to be as sick as they are and end up in coffins in our prisons, in our institutions, in our jails.

Our penal system is the largest state mental hospital system we have right now, and that is just unacceptable. So we are here back today with what we think is going to be the thread we're all trying to do here. And as you all know, we have spent billions of dollars in the last few years trying to infuse down to homelessness, behavioral health, mental health. We have stood up, standing up a whole new program platform for kids and have done a lot. Last year.

We did care court. I did Care Court with the Governor to really try to hopefully intervene in a much earlier way, those who are the most ill. We're also doing a redo this year of the MHSA, we're going to call it BHSA. So I'll talk more about behavioral health care, which will also come with a bond to be able to provide for more of those step down fundings.

A lot of people, when they object to a Bill like this will say, well we don't have the resources, but we're not making people up. These are the people that already exist, are already supposed to being served by our systems, but are very difficult. And so oftentimes they get to the back of the line or they're on 40 different 51, 50s before they cycle back out and end up committing a terrible crime and then destroying lives all across the spectrum.

So I think we can all say that the law that we currently have is not working, that the status quo is not good. The opposition will say voluntary is always best. Nobody's arguing with that. Voluntary is always best. But if somebody is naked in the middle of the street with feces on their face and a raging infection in their body, they are not going to voluntarily agree to treatment. And to let them suffer like that is not good for anybody.

So SB 43, now we've agreed with the chair, we're going to update the definition for the first time since 1967. This Bill will expand the definition to include someone with a severe substance abuse issue. Additional criteria to include their inability to meet their needs for necessary medical care and personal safety. Many of you may have followed the story of Mark Rippy. I went out in the streets and met with his family multiple times. He's been on the streets for 20 years.

Family could no longer maintain him at home. The system sent him back and forth and he ended up dying of an infection. An infection he got while living on the streets that was easily treated. But he didn't even know something was wrong with him and didn't go to the hospital to the last minute. That's on us. That's clearly on us. I'll also say this Bill removes zero due process. All the due process steps remain in effect.

This just changes the criteria for which somebody may be held. Will this increase conservative people being served? We hope not.

We hope there's enough checks in the pipeline that will get people help earlier. That is really the goal. But those who are the most ill sometimes need that extra step. We are always going to have those amongst us who are not going to be able to live independently. That is just a factor of life. And so to be able to treat people in the most humane way I think is the best way to do it. Status quo is incarceration, homelessness and death.

Leaving people to die with their rights on in the streets is nobody's vision of compassion and not the vision for California. With me here today to testify is Dr. Emily Wood and Teresa Pasquini who is a parent and we'll both talk to you today.

Thank you. Wood to another, I would like to thank the Chairman for your thoughtfulness in considering this LPs modernization Bill and the form it should take as it moves through the Assembly. The California State Association of Psychiatrists is co sponsoring this Bill because we have seen too many of our patients fall through the cracks of our broken system. SB 43 contains life saving changes to California's civil commitment laws that would benefit a distinct group of individuals and their families who have been in crisis for years.

By including all severe substance use disorders, not just alcohol. This 56 year old law is being updated to reflect today's scientific and clinical realities while retaining the due process steps and level of scrutiny that protect the civil liberties of extremely vulnerable individuals. By definition, people who meet criteria for grave disability are unable to weigh the pros and cons of treatment versus their functioning, safety preferences and values.

Without intervention, these severely ill individuals spend much of their adult life on the streets and incarcerated in jails and prisons, suffering from medical comorbidities, being taken advantage of and ultimately dying prematurely. California's behavioral health system was established on long outdated views that substance use is a moral failing undeserving of medical treatment.

Decades of research has shown that substance use disorders are brain disorders associated with functional changes in brain circuits involved in reward stress and self control that may last a long time after a person has stopped taking drugs and require ongoing effort to prevent relapse. Like other mental health disorders in their most severe form, substance use disorders deprive individuals of their capacity to choose. For this population, expecting change by requiring that they hit rock bottom is a death sentence. Without question.

More resources need to be appropriated to mental health care, including substance use disorders. And I thank Senator Eggman for working with the Governor on this issue as well. But our civil commitment law is not about funding LPs law is how we as a society express our values of protecting the most vulnerable individuals in our communities. Thank you for your time. I'm available for questions.

Thank you Chair. Thank you Chair Wood and Members of the Assembly Health Committee for this opportunity to speak on behalf of families like mine who are strong and united in support of SB 43. I am Teresa Pasquini, an army Member and an ambassador for treatment advocacy Centers, California Advocates. Today, I'm a representative voice of families like mine who are families like mine. We are unsupported caregivers and curbside caregivers who search the tenderlord or skid rows calling out the names of our beloved adult children.

We try to keep our loved ones alive and prevent them from being forced into street corners, solitary jail cells or coffins. Too often we are unsuccessful and end up visiting them at gravesides or in jails where we are forced to touch them only through glass. We watch them tremble while trying to hold the phone during a visit, while chains bind their feet and hands. We vow to never, ever give up until this inhumanity ends.

I am here today as the proud mom of an adult son who lives heroically with a co occurring SMI and substance use disorder which are brain illnesses, not behavioral choices. He was diagnosed in his teens 5150 to over 40 times on an LPs conservatorship for over 21 years and placed in multiple out of county placements.

He was arrested and criminalized as a patient deemed incompetent to stand trial, held in solitary off and on for four years before finally having all charges dropped after being diverted to a secure IMD. That placement allowed him to gain insight, achieve medical and psychiatric stability, and successfully transferred to a community placement where he has lived for the past four years with the recommendation of two doctors by his own choice. He is still on an LPs conservatorship.

I am hopeful that his revolving through all the wrong doors has ended. For someone in LPs conservatorship, an IMD level of care is the appropriate, least restricted environment and must be available to all who need that level of care. And a clinically staffed, structured step down facility in the community is critical to continuity of care. My son is alive today because he finally received continuous, medically necessary treatment in a structured, therapeutic, secure setting. After 20 years of being failed, jailed, treated and streeted.

He is currently living in safety and recovery at a Synergy program here in Sacramento. It is what I call housing that heals. We must no longer cherry pick which brain illness deserves a right to treatment and dignified housing or who's left to die on the streets with their rights on. California must lower the bar for grave disability and raise it higher for incarceration, make it easier to get into a hospital bed and housing that heals rather than a street corner or jail cell.

Families like mine are partners in care who want our loved ones to live with their rights on. This is our movement and this is our moment. And we thank you, Senator Eggman, for your fearless leadership and deep determination to be a partner in care and change with families like yours and mine. We are with you. We urge a vote in support of this Bill. Thank you.

Thank you. Others in support of the Bill. Just your name and organization, please, Mr. Chair, Members of the Committee, Randall Hager with a couple of hats here today representing the Psychiatric Physicians Alliance of California as a board Member of the Treatment Advocacy Coalition in Arlington, Virginia, which strongly supports this Bill, as well as a father of a son who is currently conserved here in Sacramento County. He has schizophrenia. Thank you.

Hello. Elizabeth Kainohopper, mother of a daughter living heroically with schizoaffective disorder and substance use disorder. I live in Carmichael.

Thank you.

Allison Monroe, Alameda County families advocating for the seriously mentally ill. Mother of a lady with schizophrenia who's alive today because of conservatorship.

Thank you.

Good evening. Melanie Klinkman, mother advocate for a missing daughter who is wandering our streets with a severe mental illness.

Thank you.

Marianne Bernard Nami, Member Member of Faisme family advocates for individuals with severe mental illness in Sacramento. Mother of a severely mentally ill adult, former counsel to state hospitals in another state that had far superior laws, and very happy to support this vastly improved definition of grave disability.

Thank you.

Good evening, Mr. Chairman and Members. I'm Moira Topp, here on behalf of San Diego mayor Todd Gloria as well as the big city mayors coalition which is the coalition of the 13 largest cities mayors in California. They are the co sponsors of the measure and respectfully ask for your I vote.

Good evening, Mr. Chair Members Ross Buckley on behalf of Sacramento mayor. Darryl Steinberg in support. Thank you. Good evening, Mr. Chair. Kira Ross, on behalf of the City of Stockton, in support. Thank you.

Thank you.

Lauren Retaliata, mother of a loved one with a serious mental illness and substance use disorder who will not take care voluntarily. Thank you. I support this Bill.

Mr. Chair Members Paul Yoda on behalf of San Francisco, Maryland and Breed in the San Francisco Board of Supervisors in strong support. Thank you, Mr. Chair. Honorable Members. David Campos, on behalf of the County of Santa Clara, we support the Bill if amended, and are grateful to Senator Eggman and the Committee for the Great work in addressing concerns, listening and look forward to reading the specifics that come out of Committee. Thank you. Thank you.

Chairmen Nick Romo. On behalf of San Jose Mayor Matt Mayhung in support.

Thank you.

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

Thank you.

Good evening. Carly Shelby with the City of Palo Alto and the Trivelli Cities coalition in strong support. Thank you.

Thank you.

Izzy Swindler with the Sutter County Board of Supervisors in support of amend.

Thank you.

Thank you.

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

Great, thank you. Opposition to the Bill. Witnesses, please come forward.

Yeah just have to push the button. It's our version of the zoom mute.

Thank you appreciate the instructions. Chair and Members. My name is Samuel Jain, attorney with disability rights California. We share the concerns of the author that there are individuals who are dying on our streets without the supports that they need to live and recover. We share the author's urgency to address the significant number of people with mental health disabilities in our jails and prisons. We share the distress of the author and sponsors of seeing our fellow Californians living on the streets.

These are our family Members, friends and loved ones. We diverge sharply on the solution. Locking people up in psychiatric hospitals for thousands of dollars a day will not fix our housing crisis. It will not solve homelessness eroding the civil rights of marginalized groups, including people with disabilities, and a disproportionate number of people of color, will not divert people from our jails and prisons. The stories shared by the author of Individuals Who Need Help already meet criteria under the current definition of grave disability.

I've represented thousands of individuals certified on grave disability and I know this law intimately. The problem is not that we don't have a wide enough net. It's that without housing, these individuals are discharged back onto the streets into the same situation without the services and supports that they need to recover. Our own State Auditor said that current involuntary criteria is sufficient. What's needed is consistently connecting individuals exiting involuntary holds to ongoing services. We agree.

Expanding involuntary criteria will only perpetuate the revolving door of homeless houselessness and institutionalization. SB 43 will not break this cycle. We shared our alternative proposal with the Chair and the author. Our proposal has three components. First, we need to mandate that housing is offered for individuals with serious and persistent mental illness. The Governor has said his new MHSA modernization proposal will house 6000 individuals. We need to house 50,000 2nd.

We need to ensure people have the support they need to stay in housing by strengthening requirements for supportive services. Currently, these requirements are too vague. Third, we need to expand our behavioral health crisis services. These systems need the flexibility to provide intervention immediately and in a way that encourages people to seek help. We need to ensure our counties have the funding to provide these services. These are evidencebased practices backed by decades of research. Unlike SB 43, SB 43 will not provide the solutions promised.

It will only add strain to an already overburdened system and pull resources from where we need it most. We urge this Committee to vote no. Thank you.

Good afternoon. My name is Claire Courtright. I'm an attorney and policy Director at Calvoices. We are a mental health peer run organization, meaning we are run entirely by and for people with serious mental illness. I'm also a family Member and a person with lived experience of these involuntary systems and was unfortunately pretty catastrophically harmed by them. I'd like to thank the Committee for its work on this Bill, and we look forward to the language That's going to come out with amendments. However, we remain in opposition.

Briefly, a few things that we've not heard discussed in prior hearings are really in the media that we think bear some discussion we'd like to touch on. And that is, first, the role of police in SB 43, because SB 43 greatly expands the role of police in an unprecedented fashion in every county in California. The people, and the only people who can take a protesting person physically into custody against their will are the police.

And at a time when we're trying to get police out of behavioral health response across the country, because far too many disabled people and far too many people of color are dying in encounters with police, SB 43 puts them right back in. And the nature of the criteria in SB 43 are not something that police are particularly good or qualified to assess. Do you have a medical condition? Is it serious at the street level?

This is all first blush, and we're concerned about the role of police specifically because this Bill is often mentioned in tandem with clearing encampments. We'd also like to focus some conversation, hopefully, around the inclusion of medical care as a grounds for a hold. It creates a legal mismatch, although people, proponents of this Bill often say that it sort of applies to unhoused people, people who are incompetent, people who are seriously medically ill, et cetera, That's not accurate.

And there's a mismatch between the medical incompetence to be placed on a hold in California does not involve an adjudication of incompetence. So you're talking about putting people on a hold for failure to attend to a medical condition, but you cannot treat those people because they are actually not deemed incompetent. So those people back up in our Ers because they cannot go to a mental hospital or to another facility that doesn't treat medical conditions is another serious condition with serious consideration for expanding.

And I think I'm just about out of time.

Thanks. Thank you. Others in opposition.

Good evening. Linda Way with Western Center on lawn poverty opposed? Thank you. Susan Gallagher with Executive Director of Cal Voices. Civil rights matter. We are opposed.

Thank you.

Hi, everyone. Rachel Bogwitt with ACLU. California action strongly opposed. Thank you.

Catherine Wolf, interim Policy Director of and. On behalf of the Disabled Students Commission. Of the Associated Students of the University. Of California in opposition.

Thank you.

Danny therickel on behalf of Mental Health America of California and the California Youth Empowerment Network. In opposition. Thank you. Good evening. Avery hulag Vicente. I am a peer with lived experience. I am also here on behalf of Campro California Association of Mental Health peer run organizations. We are in strong opposition.

Thank you.

Paul Simmons with the Depression and Bipolar Support Alliance of California and also the father of a young lady who when she was younger was put into involuntary treatment and when she got out, she became homeless and attempted suicide. It's not the answer.

Thank you.

Mr. Chair and Members, Robert Harris on behalf of SEIU, California. We have a position of opposed unless amended. We would like some fiscal things taken care of that aren't addressed and we think you need a little bit deeper understanding of what Sud is and how it works. Thank you.

Thank you.

Izzy Swindler on behalf of the Fresno. Kern and Solana Board of Supervisors in opposition. Thank you. Okay, thank you. Anyone else? Are you kind of tweeners or OK. All right.

Good evening, Mr. Chair and Members. Jolio Nadera with the California State Association of Counties also here tonight on behalf of the county Behavioral Health Directors Association with a position of concerns, did want to both thank all of the efforts regarding the amendments agreed to in concept as outlined in your analysis and look forward to continued discussions.

Thank you.

Kelly Brooks, I'm here on behalf of the urban counties of California and the Rural County Representatives of California. We also have concerns and look forward to working with everyone on the measure as it moves forward.

Great, thank you. Okay, I'll bring it back to the Committee. I know Ms. Waldron has some questions.

Thank you, Mr. Chair. I'd like to thank the author for all of her hard work in this issue in this space through the years and this particular Bill. We know people are falling through the cracks due to the lack of an appropriate definition. Basically the standard has been basically the same for almost 60 years and it's a serious barrier to getting people that needed help they need. But also the comments about your adult child.

I mean, when I'm in the district and I talk about things that are going on in Sacramento, I always talk about mental health issues and substance use issues. And every single time people come up to me after the meeting and they're amazed at what we try to do, they're amazed that I even talked about it at all. A lot of times it's parents of adult children because that's where it's so difficult for parents to even know what's going on.

You're the loved one of that person and just because they're over 18, all of a sudden you can't even know where they are or what's going on with them. The criminal justice system can never address the ultimate causes and especially with mental health and co occurring disorders regarding Sud.

And That's why these amendments, even though they're not in print and just being able to narrow down onto these and get these defined is making this actually one of the most important bills we're going to be voting on, I think, this year because of the amount of impact it could have in our communities. I always say a civilized society cannot continue to ignore the humanity of people who are on the streets, in the conditions that they're in, who are literally dying in our streets.

So I'm very supportive of this Bill. Thank you.

Mr. Mccarty. And then Dr. Weber.

Yeah, thank you. And just wanted to continue with where Assembly Member Waldron noted and just frankly thanking Senator Eggman for leading on this issues even when you were in our house. I know we had a multi hour informational hearing about this a couple years ago, Dr. Wood. And these are painful proposals and they're not easy. I know that people that aren't supporting these proposals are your allies over the years coming up as a social worker and somebody who wants to help people.

But there's a reason why these are passing with unanimous support over and over, because we know both sides of the aisle, up and down California, from rural California to right outside the state capitol to Stockton to the North Coast. Dr. Wood represents that the status quo was just not you know, I read with great pain that the profile what's the individual's name again? Mark Rippy. Rippy, Solano County.

Yeah, when they profiled this individual just down the street and his family was just given this example and he's just one. And I don't know people's names, but I know there's a woman right by our kids middle school down here at Sutter, the same example, and she passed away after we could not get her the help that she needed.

And the line that you have been using is just sticks with me that we have these rights, this policy that we created in 1967 that we thought would be working in the community, would rally and help on a community basis and get rid of the state institutional programs. And you say that people are dying with their rights on, and that is so truth. It's so true. And you know what? The truth hurts sometimes. And this is exactly what this is about. And I am in support.

I'm going to be a co author, and we're working on this. If not, please note that staff and we have these same tough conversations with care courts last year, and there's not one thing that we can do. Nobody has the secret plan to deal with, you know, cascading issues, know, mental health, intergenerational poverty, homelessness, all those things in one.

But this is, in my view, a key piece of the puzzle because the definition I went on a ride along with our firefighters here, Sacramento, a month ago. They said, yeah, you have to either be threatened to kill somebody or essentially about to kill yourself. And this gravely disabled thing doesn't really work. And they just gave me these crazy examples and I was like, Are you kidding me? We can't help take that person in, even though their family wants to. Like, no slip through the cracks.

And too many people slip through the cracks. But I do think that there is one legitimate thing that we need to address and I want you to answer. I know you're answering the call with the other legislation that you're working on with our chair, and that is once basically this box is checked on whatever someone's form or app or phone that, hey, we're going to utilize this tool to help this person, not turn them in, to literally help them. The placement.

I know the same thing with Care Court, so can we talk about that for a little bit? And what's your response on how we would have the number of beds? I heard one gentleman here say we don't need 6000, we need 50,000. So I'm not sure if That's accurate, the numbers, but can you enlighten us on this issue?

Yeah. You've all been here and known how much money we've been sending down, right? We are now on our fifth round of the program to Fund additional facilities and all of that money has been so those are all going into effect as we sit here today. There has been how many, Jim? $5 billion has gone down in the Bridge program and we're now going into round five. And we pushed back with the Administration who wanted to hold that last round to get it out.

So all of those have plans for new beds to be built. We are working with the Administration on the Behavioral Health Initiative, which will come with the bond and with more funding for beds, for step downs, for villages, for housing that heals all of those things that are so important. I will also add that a few weeks ago, this Committee passed out a Bill I did on the online on time database.

Because currently, if you go to try to get someone a placement, you're still looking at an old notebook and trying to call, do you have a bed? Do you have a bed? Do you have a bed to be able to say, I mean, we have AI, we have everything that can tell us directions, how to bank, how to do anything.

We can certainly have an online on time database that tells us where is the bed, where's the SUSD bed, where's the lock, where's it secure, where's a step down? So that is going into effect as well. And we are open to just because to give the county some time. One of the amendments we've agreed to with the Chair is to have some of the areas really wanted to go right away with SB 43, but we have said goes into effect on 24.

But any Board of Supervisors can take a vote to delay the implementation until 25, to give people chance for the bond to pass and for more facilities to come on board. So capacity is always going to be an issue, but we have to start I mean, we have to start somewhere. And we have been increasing, increasing. We have multiple new facilities and we have to be able to have our funding to match that.

And so with the expansion of Medi Cal and with the potential waiver that we have coming, I think as long as we have payment sources, the beds won't be as big of an issue. And currently, again, people are just staying on the streets and or going to prisons, and that certainly is not the issue.

Yeah. So maybe two more issues here. So how does this proposal, it's not this Bill here that you're working with Dr. Wood and the Governor on kind of repurposing Modernizing Mental Health Services Act.

Right.

So That's a piece of this. But not the only piece.

That's right. Right. That's not the only piece. I mean, the pieces are the pieces that we have been putting together for housing. I mean, for the housing, for housing. For housing is what we've been putting together to 12 billion on homelessness, I think. And I want to push back on the opposition, who says we're talking about this in conjunction with clearing Encampments. That is no part anywhere of anything that I've ever said that we're going to clear encampments by conserving people.

That does not ring true to me. And anytime a police officer intervenes with a person, that person has then taken to a facility where they are assessed and held or not held. It is not up to the officer on the street for the continued placement of somebody. And again, this takes away no part of due process of the case.

But, yes, for the payment, the three pots, one of the pots will be just specifically used to be able to house people, and that's to be able to pay for the housing, for the implementation and all those components. The other big pot will just focus solely on those with the most severe issues. And then the third pot will then be for that early intervention to try to really get in on early psychosis.

We know That's one of the most important things we can do, and I'll say that's probably what I'm going to be working on next year, because I don't think the state does a good job of doing that. Of the early intervention on early psychosis, incredibly important, and that'll be in that third bucket. So some of the upfront things that we were doing before that we thought were going to be a good idea around innovations, we still want some of that.

But I think that we can all agree that for right now, we have a mental health crisis as it reflects those who are the most ill, who we should be treating first and not last. And I have to say it's dr. Susan Parvodi partovi I practice saying it, who's a psychiatrist in Los Angeles who did that term.

People are dying with their rights on because she was saying we could say, okay, he's going to die tomorrow, she's going to die the next day, and then go back and find them dead, but with their rights on.

Okay?

And then lastly, Mr. Wood, one more question. So I do appreciate the recommendation to expand substance abuse disorder because clearly there's.

That and it's severe. It's ibga's going to lock up people who have a glass of wine or smoke weed. That is not what we are talking about.

And there's the combination there, thank God, right? There's a combo there with people who are homeless and mental illness and addiction and all three of those together. It creates issues and expands it. So just give us a hypothetical so hopefully there won't always be police responding. Some cities, like our cities, are having alternative response out there, and we funded a lot of that. Right.

Part of our bridge, when you find somebody who triggers it, like Mr. Rippy, and then they take him to this place for the evaluation, what they're saying is there's not going to be enough spaces. What happens at that point is that the evaluation says, yes, we think that you meet this definition, but there's nowhere to go. So what happens to that person then? And what do we do?

Well, I would say it's a system's responsibility to respond. I mean, we keep talking about this issue as though it's separate from any other health care issue, right? When a woman is having a baby and she goes to the hospital, we don't say, I'm sorry, we don't have a bed for you right now. You're going to have to go to the streets, go to jail. They have places you can deliver, right? Have cancer. We don't say, I'm sorry, we don't have the proper.

We do our very best to treat them. And I think that's what we need to have our system do. Again, we're not making these people up. They live in the community. They are citizens of the community. They are deserving of the services. I would ask Dr. Wood if she wants to respond to that any further. But I think beds can be found if the criteria is met. And we have been investing in the system in huge ways.

And I'll just say the opponents, they want to talk about the auditors report. They did not support my AOT. They did not support my AOT step down with drugs. They did not support any of the other interventions that we have done that the Auditor suggested. So, I mean, either you love the Auditor or you don't. And it was the former Auditor. Dr. Wood.

Yeah, I think that there's a misunderstanding, firstly, about the size of the group we're talking about here and also about how we treat individuals with severe mental illness and severe substance use disorders so we can treat them in the same facilities. A person who is gravely disabled, and we mean very ill due to their substance use disorder can be in a psychiatric hospital until we can find a more suitable placement for them.

And as Teresa knows very well, while there is a place for some individuals in locked facilities, there are many people who are on holds who do not need to be in locked facilities but do need a very high level of treatment and supervision during the time that they are getting more well and getting some more insight back. So right now, we believe we have the beds available now for these sick people.

And part of the thing that we are happy about is that these other beds in the community are already coming on board because those are the reasons our hospitals have been staying full, is not being able to get people out to those longer term housing alternatives. So we believe we have the capacity to take care of these very ill people right now.

Okay, thank you.

Thank you, Dr. Weber.

Thank you, Senator Eggman, as others have stated, for really being a champion in this, really, really appreciate all the work that you have done, all of the bills that you have brought forward, and all of the discussions that you have incited amongst both the Assembly and the Senate around this issue. So with the definition of gravely disabled, who specifically would be giving an individual that a provider, right?

Yes.

And the reason why I ask is I want to ask the opposition, because you stated something about the issue of encampments. And in my area, I represent parts of San Diego, and people very well may know about the San Diego unsafe camping ordinance that was just passed that does deal with the issue of encampment. So how would this increase the interaction or people being taken off of the streets if someone has one of these encampment ordinances?

Yeah, I'm not familiar with the encampment ordinance in question, so I can't speak to that. But I can say that in every county in California, the people who can categorically write a 5150 hold on their own are police. And we have pretty typically seen them be our first responders across the country. And however exacting the legal standard may appear to be on paper, I know the Committee put in all of the Dsmi criteria for serious Substance use disorder.

A police officer is just not qualified to do that. And so the concern is there's a real temptation to pick up unhoused people on the streets. And I don't necessarily have an opinion about it, but there's lots of reporting that there's been really aggressive efforts in some places by police towards the unhoused. And this puts a tool in their hand they didn't have before. And unfortunately, we know those interactions go sideways a lot.

So now what's in their hands is somebody appears to be a substance user, someone appears to have a medical condition, or someone appears to not be attending to their safety. Now, we don't know what the final definitions of all those will be, but I think it's clear That's an unprecedented expansion of things police can do compared to now.

I'll also say the current language in the Bill says that if an individual is unable to utilize adequate shelter, then that can be used as evidence to take individuals in on a 5150. So that specific language is very concerning. If an individual chooses not to go to a shelter and they choose instead to stay on the streets, that could be interpreted as someone not utilizing adequate shelter, and that impacts a lot of individuals and could be used to erode their civil rights.

That is amended out of the Bill.

Yeah, thank I was going to say.

The thing that is amended out of.

The Bill any longer okay. In this Committee's amendments.

Yes.

Okay.

Are they not in print? This is complicated.

Okay. So that part is taken out, the utilization of adequate shelter. Good, because I did, as I was reading it, circle that one part specific to the ordinance that was just recently passed in San Diego.

Now that we will have our individuals who are on the street and encampments approached by police officers, I wouldn't want someone to be given the diagnosis of, zero, you must have a mental illness, and you've got serious harm to yourself because you don't want to take the shelter that we're asking you to take at this point. So thank you for that clarification.

Thank you, Dr. Weber. Anyone else? Mr. Rodriguez.

Yes.

I want to thank the Senator as well for all the work you've done in and around this arena. I know we sat on health together, I think, a while back, and we talked about issues like this. So obviously we're living in different times now. Right. And licking what you want to do to include the substance use disorder. I think it's way overdue. Right. Because what we see in the streets and just hearing from my son is an officer out there.

He's on patrol, and he would say probably eight out of 10 of the homeless are suffering from this. Right. And it's something we need to do. So I really thank you for bringing this forward and looking forward to support. And once again, thank you for all that you do. And hopefully this is something we move forward to help address the issues on the streets with the folks needing the help necessary. Thank you.

Thank you.

Okay. Thank you. Senator Eggman. Thank you. It's always a pleasure working with you, although at times, I know we probably get frustrated with one another, but only for the best reasons. So we have a long history, and I appreciate that very much. I think one of the beauties of the current Legislature, the way it's built, is that there is an opportunity for people to become subject matter experts and be able to use their expertise to help with public policy.

And so I appreciate that about you and always have. And thank you for your work on this. Appreciate your working through these challenging amendments. And then obviously, we have other tasks. Ahead of us as well.

And so I look forward to working with you as well on that. So the Bill does enjoy do pass recommendation. And as it moves forward, should it leave the Committee, I would like to be considered as a co author of your Bill.

Thank you very much.