Senate Standing Committee on Health

Thank you, Madam Chair and Members, I'd like to begin by thanking the committee staff for the suggested amendments, which I accept.

AB 4 directs covered California to expand access to affordable health care coverage to all income-eligible Californians, regardless of immigration status. The historic exclusion of undocumented immigrants from the healthcare system threatens the well-being of individuals and families in our communities. We have been working to end this exclusion through recent efforts to expand full scope Medi Cal coverage to all income-eligible adults.

Thank you.

However, undocumented individuals who are ineligible for Medi Cal are still restricted from purchasing coverage on the Covered California marketplace if they're just over those income limits. By removing immigration status as an eligibility barrier to Covered California, we can build a more universal equitable healthcare system for all who live in California. It is time to recognize that healthcare access is a human right and remove exclusions to vital health care access. Testifying in support is Jose Torres Casillas with Health Access.

Mr. Casillas.

Good afternoon, chair and Member. As stated, my name is Jose Torres Casillas with Health Access California. I am also representing the California Immigrant Policy Center, the two co chairs of the Health For All coalition, and sponsors of AB 4. Over the last ten years, the coalition has worked to remove immigration status as a barrier to eligibility within our healthcare system. We have made tremendous progress by removing immigration status as a barrier within our Medi Cal program.

Currently, 630,000 individuals have gained healthcare coverage, and beginning in six months, an additional 700,000 people will gain coverage when the final program expansion begins. Implementation. That's over a million undocumented people who now have access to preventative and primary care. While we have made such great progress, there continue to be barriers within our healthcare system that still prevent undocumented people from access to health care. Medicao has an income threshold for one person that is less than $20,000 per year.

Normally, a person who has an income above this limit would be able to purchase coverage on Covered California and receive affordability assistance. However, undocumented individuals are not able to enroll within Covered California. AB 4 takes the first step in addressing the systemic disparity that undocumented people face.

It would have covered California, establish health plans that would be identical to those offered on the exchange, but undocumented individuals would be able to enroll in undocumented Californians with an income above the Medi Cal limit would for the first time, have access to the same quality covered California plans as documented individuals. This continues the work and leadership we have done here today to make our healthcare system more equitable, to ensure that everyone has access to our health care system, regardless of where they were born in.

The work continues. LA Luciasigue, in seeking to ensure that our neighbors, our friends, our family have access to healthcare coverage. I thank you for your time and ask for your support here today.

Thank you very much. Next person speaking in support.

Chair Members, Kathy Mossburg, representing the California Immigrant Policy Center, will associate ourselves with our other co sponsor and urge aye vote today. Thank you for your time.

Thank you very much. Now, people, just name an affiliation.

Robert Harris with SEIU California in support.

Thank you.

Kiran Savage, California Panethnic Health Network in support. Thank you.

Thank you.

Nicette Short. On behalf of the Alliance of Catholic Healthcare, In support.

Thank you.

Nora Lynn for Children Now in support.

Thank you.

Marvin Pineda with the Leukemia Lymphoma Society in support. Thank you.

Thank you.

Kelly Brooks with the Board of Supervisors of Santa Clara County and the Urban Counties of California in support.

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

Faith Lee with Asian Americans Advancing Justice Southern California, we're in support.

Thank you very much. Anybody speaking in opposition to this Bill today? Seeing none. We'll go to the phone lines now. Speaking in support and or opposition, now is the time. Just name and affiliation and position. Is there anyone in the queue? Moderator.

Yes. If you'd like to express support or opposition to this Bill, please press one and zero at this time. And our first line is 156. Please go ahead. Your line is open. Our next line is 170. Please go ahead.

Hello, Daniel Anchis on behalf of CHIRLA. In support.

Thank you. Next caller.

Next line is 174, please go ahead.

Hi. Gabrielle Lessard, National Immigration Law Center in Support.

Thank you. Next person, please.

Line 176, please go ahead.

Hello. This is ... with the Latino Coalition for Healthy California and Strong.

Thank you very much. Next caller, please.

Line 179, please go ahead.

Hello, Luz Gallegos. With TODEC Legal Center in support.

Thank you very much. Next caller, please.

Line 180, please go ahead.

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

Thank you.

Next caller, line 182, please go ahead.

Good afternoon, chair Members. Chris Myers with the California School Employees Association and strong support.

Thank you. Next caller, please.

Line 163, please go ahead.

Hello, my name is Savanna Hogan with Venice Family Clinic and we are in support of AB 4.

Thank you very much. Next caller, please.

Line 184, please go ahead.

Hello. This is Mandy Diêc with Southeast Asia Resource Action Center in support.

Thank you. Next caller please.

Line 165, please go ahead.

Hi, this is Veronica with Christianicom Promiso in a strong support.

Thank you.

Next caller, line 173, please go ahead.

Good afternoon, Samayla Har on behalf of the California Dental Association and support, thank you very much.

Next caller, line 169, please go ahead.

Hello. My name is Alondra Mendoza with the Mixteco/Indígena Community Organizing Project. We are in support of AB Four.

Thank you very much. Next caller, please.

Line 172, please go ahead.

Good afternoon, chair Members. My name is Andrea Chirino from UCLA Center for Health Equity. We are in support of AB 4.

Thank you very much.

Next caller, line 147, please go ahead.

Good afternoon, chair and Members. James Michael Powell with the American Federation of State County Municipal Employees in support.

Thank you. Next caller, please.

Line 164, please go ahead.

Hello, my name is Juan Carlos Diaz and I am with Mixteco/Indigena Community Organizing Project in support of AB 4.

Thank you very much. Next caller please.

Line 156, please go ahead.

Go ahead, please. Let's move on. Moderator.

Line 167, please go ahead.

Hello. My name is ...with APLA Health. Strongly support 84.

Thank you. Next caller, please.

Line 185, please go ahead.

Good afternoon, chair Members. My name is Jose Vargas with United Ways of California in support.

Thank you. Next caller, please.

Line 161, please go ahead.

Good afternoon, my name is Carla Mercado, I'm a fellow at California Health Plus Advocates and we are in support of AB 4.

Thank you very much. Next caller please.

Line 189, please go ahead.

Craig Pulsipher on behalf of Equality California in support.

Thank you. Next caller please.

Line 191, please go ahead.

Good afternoon. Lynn Kersey with Maternal and Child Health Access in strong support of SB 4. Thank you.

Line 190, please go ahead.

Hello. Andrea Bolaños with Services, Immigrant Rights, and Education Network in support of AB 4.

Thank you, thank you. Next caller please.

Line 192 please go ahead.

Libby Santas on behalf of AltiMed in support.

Thank you. Next caller, please.

And Madam Chair, I have no other lines queued up at this particular time.

Thank you very much. We'd bring it back to the committee now. Questions, concerns? Okay, would you like to close, sir?

Thank you for the opportunity to present. Thanks again to the committee for all the hard work on this Bill. And when the time is appropriate, I respectfully ask for an aye vote.

Thank you. Dr. Arambula, thank you so much for your longtime work and focus on making sure health care is extended to everybody in California. I appreciate it and I admire it. Thank you.

Thank you.

Okay, moving on to AB 40. I see Assembly Member Rodriguez here. Come on up, sir. It go ahead.

Thank you. Madam Chair and Senators, thank you for the opportunity to present AB 40, a bipartisan Bill that takes several steps to prevent ambulance patient offload delays to ensure ambulances are available to respond to 911 calls for emergency medical services. First, the Bill would require all EMSAs to establish an ambulance patient offload time standard, also known as APOT, of no more than 30 minutes 90% of the time. Currently, there is no EMSAs with an established APOT standard greater than 30 minutes.

AB 40 would also require hospitals to develop an APOT reduction protocol and file the protocol with their local EMSAs. Hospitals would have the flexibility in determining how to improve hospital operations, including additional staffing, or improved triage or transfer systems. As someone who has spent over 30 years working as a first responder in the emergency medical services system, I am all too familiar with wall times. Excessive wall times have been a problem for decades.

In fact, I have personally waited for over 12 hours at a hospital emergency Department to transfer a patient to a hospital staff. According to a 2020 EMSA report, each year, roughly 70,000 Californians wait over an hour for an ambulance gurney once they arrived at the hospital. Not only do wall times result in untimely care for patients experiencing an emergency, but it prevents EMTs and paramedics from responding to other emergencies.

I personally have worked on this issue for over three years and have met with stakeholders numerous times, toured local facilities, and introduced legislation to help find a solution to wall times. As a result of these efforts, EMSA convened a wall time task force in November 2021. In June 2022, the EMSA Walltime Task Force voted on 19 recommendations to mitigate ambulance patient offload delays. This Bill codifies some of the most impactful recommendations, including better data collection.

With that, let me turn it over to my witness in support, Brian Rice from President of the California Professional Firefighters, sean Burrows, President of the Alameda County Firefighters Local 55 and Doug Suburbs with the California Professional Firefighters to answer any technical questions. Thank you.

Saw you just a couple of minutes ago. I feel like we did. Nice to see you again. Please.

Good afternoon, Madam Chair and Members of the committee. My name is Brian Rice. I am the President of the California Professional Firefighters, and I represent nearly 35,000 professional firefighters and emergency medical services personnel statewide. I also served for over 30 years here in Sacramento with the Sacramento Metropolitan Fire Department. CPF is a proud sponsor of AB 40, and I'd like to thank Assemblymember Rodriguez for his leadership on this issue.

And also thank you, Senator Eggman and your committee staff, for the engagement on this measure and the discussions. Last year, a battalion chief from Sacramento testified that a patient experienced a severe medical emergency four blocks from a hospital, but the only available ambulance came from 8 miles away in three cities over and was otherwise in the CAD system, the 20th pick in the ordering system. When ambulances are stuck on the wall, they can't do their jobs protecting the public.

That means longer and longer response times for other patients when seconds count. This also creates costs to the taxpayers by forcing firefighter EMTs and firefighter paramedics and private ambulance EMTs and paramedics to effectively subsidize the staffing of hospitals while they wait to transfer patient care. In 2022, the Anaheim Fire Department had units held on the wall for over 5800 hours. This equates to two full time, 24 hours. Units staffing the ER in the city of Anaheim with no renumeration for the city.

Between January and May of 2023, EMS crews were held at the emergency departments in Sacramento County for more than 14,850 hours that's January through May, resulting in a cost to local agencies, cities, counties and special districts of $3.1 million in Walkheim costs. That's just for five months. That equates to nearly 100 hours per day that these units were not able to respond to an emergency. Just in Sacramento County. And Sacramento County has a system of approximately 45 Medic units.

You can kind of look at that, and I'll be very conservative, but you could take two to three of those out of service for 24 hours, and they never respond to a call. That's what those numbers look like. AB 40 will set a statewide cap of 30 minutes for ambulance patient offload time and direct each EMSAs to adopt a standard. As noted in the analysis, a significant number of local jurisdictions have adopted a standard of 20 minutes or less.

AB 40 will also require hospitals to develop and implement a protocol to reduce offload times if they exceed the standard. Having hospitals, we know that hospitals have struggled with COVID-19 and the increasing demands on the healthcare system. There's no doubt about it. Just like every single emergency pre-hospital provider suffered the same kind of hardships and difficulties during the pandemic. This is not a pandemic caused issue. This is a systemic issue that has been in play for well over a decade.

And I fully recognize that the entire healthcare system has been experiencing the challenge and that this Legislature has stepped up to work to address some of the challenges between the chair and this committee's. Work on improving access to behavioral health treatment, community paramedicine, the distressed hospital loan program and the MCO tax substantiative steps have been taken to support our healthcare delivery system.

But the challenges faced by hospitals, challenges that are mirrored in prehospital care, can't be an excuse to put an endless tap on taxpayer funded emergency service responses within our communities. The health and safety of our communities depend on fast, effective, fully staffed, and available medical response teams. That can't happen when ambulances are stacked up in the ER waiting to offload their patients. For these reasons and many more I respectfully request your support on AB 40. Thank you.

Thank you, President Rice. Next person, please. You have about a minute and a half left.

All right, great. Thank you. Good afternoon, Chair Eggman and Members of the committee. My name is Sean Burrows. I'm a 27 year veteran of the fire service and I currently serve as a fire captain paramedic for the Alameda County Firefighters, as well as President of the Alameda County Firefighters Local 55. As you have heard from Assembly Member Rodriguez and President Rice, ambulance patient offload time or wall times, continues to grow and firefighters throughout the state are being pushed to the brink.

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

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

These delays are not one offs and they're not anomalies. They occur daily and they happen throughout the state. My brothers and sisters across the state are being stretched to their breaking point, whether it's a 45 minutes wait for a young adult experiencing a seizure in Long Beach, or even being told that there is not a single ambulance available to help a dying child in Oakland, this cannot continue.

We go to work each day to perform the difficult and dangerous jobs in service to our communities, but there must be acceptable and actionable steps taken to reduce the strain on our system.

Thank you very much.

Thank you. Okay, other people now just speaking in support. Name and affiliation, please.

Thank you.

Good afternoon. Chair and Committee Nick Cruz of the California Labor Federation in support.

Afternoon. James Michael Paul with AFSCME California in support.

Thank you.

Good afternoon. Dr. Dan Haverty, fire chief for Sacramento Metropolitan Fire District. We pledge our support.

Thank you.

Madam Chair, Members of the committee. Frank Molina, on behalf of the San Manuel Band of Mission Indians, in support.

Thank you.

Good afternoon. Robert Harris, on behalf of SEIU, California, in support.

Thank you.

Good afternoon. Adam House, battalion chief, Sacramento Metropolitan Fire District. Pleasure for support.

Thank you.

Good afternoon. Jeff Willis on behalf of the Fire Districts Association of California in support.

Thank you.

Luis Marquez, on behalf of the California Ambulance Association and the Rincon tribe of Luiseno Indians, in support

Jeff Neal, on behalf of the City of Chula Vista in support.

Good afternoon. Sarah Nocito. On behalf of CALNENA, the California chapter of the National Emergency Number Association in support thank you.

Good afternoon. Alex Hamilton, Fire Chief for the City of Oxnard Fire Department in support.

Thank you.

Good afternoon. Dave Spencer, Fire Chief for the City of Auburn in support.

Thank you.

Good afternoon. Ted Peterson, Deputy Chief representing California Fire Chiefs Association in support.

Thank you.

Good afternoon. Frank Crespo, on behalf of Hayward Fire Department and Local 199 in support.

Thank you.

Good afternoon. Gerald Jacobs, firefighter, Alameda County Fire Department in Support.

Thank you.

Local 230. San Jose firefighters in support.

Thank you.

Chair, Members, Jonathan Feldman, with the late support from the 911 Ambulance Alliance.

Thank you. Michael Gold, Battalion Chief, City of Lodi Fire in support.

Thank you.

Priscilla Kudos, here on behalf of the City of Santa Monica, in support.

Thank you.

Good afternoon. Ryan Henry City Vice President Sacramento firefighters, local 522. In support.

Thank you.

Hey, there. Seth Olyer, Oakland firefighter. 25 years and Local 55 Vice President in support.

Thank you.

Jeremy Bishop, Captain, Stockton Fire Department. In support.

Thank you.

Dustin Rodriguez. Local 522. In support, thank you.

Matthew Cole. Sacramento Area Firefighters. Local 522. In support.

Thank you.

Tilden Builder, deputy chief, Sacramento Fire Department in support.

Thank you.

Robert Weber, Sacramento Metropolitan Fire District Board of Director in support.

Thank you.

Ben Kim, President of the Alameda City Firefighters Local 689, in support.

Thank you.

Good afternoon. James Magnuson, St. Paul Fire District Division Chief in support.

Thank you.

Ian Bernag, Berkeley Fire Local 1227 in Support.

Thank you.

Good afternoon. Chris Cobia, San Jose firefighters. Local 230 in support.

Thank you.

Good afternoon. Matt Tuttle, President, San Jose firefighters, Local 230 in support.

Thank you.

Good afternoon. Amori Langmo, President of the Berkeley Firefighters. 1227 in support.

Thank you.

Stephanie Estrada on behalf of the City of San Jose in support thank you.

Thank you.

Good afternoon, Madam Chair and Members. Ross Buckley on behalf of the City of Sacramento and Mayor Darrell Steinberg in support.

Thank you. Chief, you said you were speaking on behalf of your brothers and sisters. I just saw your brothers. You didn't bring any sisters. So anyway, Madam Chair, I think this. Is another reminder of how much more work we need to do to we. Have a lot of work indeed. Okay, so let's hear from the opposition now.

Good afternoon, Chair, Admin, and Committee Members. My name is Dr. Brandon Lew. I am the Emergency Department Medical Director at Huntington Hospital and affiliate of Cedar Cyanide in Pasadena. Serving the San Gabriel Valley. Huntington is a 650-magnet-bed hospital and the only level-two trauma center in the region. It's serving a population of approximately 265,000 individuals in the San Gabriel Valley and the surrounding areas.

As a full time emergency medicine physician for over 32 years, I have seen firsthand the changes to emergency medicine, and the new normal is significantly different than it was five years ago. Ambulance patient offload delay is a problem that cannot be solved by hospitals alone. While AB 40 is well intended, it is an oversimplification of the issue. This is not just a hospital problem. It's not just an EMS provider problem. It's a healthcare delivery system problem.

Let me tell you a little bit about how my ED typically looks. On any given day, we have 54 treatment stations and see an average of about 210 patients a day. This past weekend, we had 15 patients boarding in the ED, which means that they were ready to leave, but there was no available bed for their next level of care, so they had to stay with us until they could be transferred.

That brings us down from 54 treatment spaces to just 39 to care for 210 patients. Treating patients as quickly as possible comes with other challenges, such as workforce shortages for both hospitals and EMS providers. In addition, we are also facing a behavioral health and homelessness crisis that continues to grow. A recent study found that ED visits by the individuals experiencing homelessness has nearly doubled between 2018 and 2021.

In order to treat the high volume of patients, emergency departments use a clinically driven process to evaluate, triage and deliver appropriate care to everyone who seeks help at a hospital, regardless of how they arrive. I am extremely concerned with AB 40, creating a standard that our ED will not be able to meet and will make caring for patients even more challenging if we are trying to meet an arbitrary offload standard rather than treating patients based on acuity level.

I'm also concerned about the unintended consequences of AB 40 if it's signed into law. For example, this Bill will incentivize misuse of an overly burdened EMS system and has to potentially to radically shift and increase costly ambulance utilization. I often have people arrive by ambulance for issues such as back pain, sore throats, minor cuts, because they think they will be seen faster. This, of course, is not the case. They will be sent to the waiting room after they have been triaged.

Ambulance patient offload delays are a complex, long-standing issue exacerbated by the pandemic resulting from challenges across the entire care delivery system. I share the EMS's provider's frustration, but rather than putting the blame on just one piece of the puzzle, we should be looking at the solutions across the entire healthcare delivery system. Huntington Hospital is eager to be part of the solution and work together with our EMS partners to reduce delays and to allow us to focus on our patients.

However, AB 40 will only put more strain on an already broken system. On behalf of Huntington Hospital, we respectfully request your no vote on AB 40. Thank you.

Thank you very much. Next person, please.

Good afternoon, chair and committee Members. My name is Rose Colangelo. I'm here today on behalf of Sutter Health in opposition to AB 40. I have spent 23 years as a trauma ER nurse in the past three years at Sutter Roseville Medical Center as the Director of Emergency Services. In addition to my role at Sutter Roseville, I lead Sutter Health system-wide committee to address Apot in all 21 of our emergencies in Northern California.

One challenge I've come across is significant inaccuracies in the offload times reported by ambulance personnel compared to what is recorded in the hospital's medical record. As we all know, data drives change. We should not set laws and standards based on flawed data. For example, Sutter works with over a dozen lenses. We've reached out to ten for data validation purposes, and only two allow us to audit the data. Unfortunately, we've only been successful in getting data corrected for one audit.

To give an example of how the flawed data is, how flawed the data is when doing our own audits of the data, we found many instances of patients that were never in our facility but were on our Apot report. Patients that were having heart attacks and were listed as Apot times greater than an hour, but that had already been treated and were in hospitals ICUs when the Apot report was showing that they were still on our wall.

Additionally, there are inconsistencies with the start and stop time. Every ambulance provider does this differently. Through CHA. We offered amendments to clarify the process for when the clock starts and stops, and these were rejected. While we appreciate that the Bill includes the development of an E Signature and audit tool, we have concerns with the implementation timeline in the current language. The local EMS agencies must set a standard by March 1, 2024.

Yet MSA is not required to develop and implement their audit tool and Esignature until June 1, 2024. We believe this is like putting the cart before the horse. MSA should create and begin implementing a system to ensure that the data is accurate, being collected and used to calculate Apot times before local time standards are put in place. Furthermore, hospitals are going to be held to these standards on July 1, leaving only 30 days for hospitals and EMS providers to wrap up these new procedures. That being said, we are committed to this work and ensure to get it right, but this can only happen with a realistic implementation timeline or a phase.

In thank you very much.

Ramp up approach.

Thank you very much. Other people speaking in opposition now just name an affiliation, please.

Vanessa Gonzalez with the California Hospital Association here in opposition to AB 40. Also able to help answer any questions that you may have.

Thank you.

Karen Lang, on behalf of the Solano County Board of Supervisors, in opposition.

Thank you. Thank you.

Hi, Greg Hayes here on behalf of Providence Hospitals and at 17 hospitals in California in opposition.

Thank you.

Jonathan Clay on behalf of Scripps Health in opposition.

Thank you.

Kiran Gadani here on behalf of the California Children's Hospital Association in opposition.

Thank you.

Angelica Gonzalez with Kaiser Permanente opposed unless amended.

Thank you.

Kelly Ash with Dignity Health opposed. Thank you.

Thank you.

Nissette Short. On behalf of the alliance of Catholic Healthcare, Rady Children's Hospital, and Adventist Health in opposition.

Thank you very much. Okay, now we'll go to the phone lines. Operator, are there any calls in the queue? And now it's name, affiliation, and position on the Bill. And we're talking about AB 40, madam.

Chair, as she stated, if you'd like to take this opportunity, please press one followed by zero. If you're in support or opposition to AB 41 followed by zero. Line 175, you are open.

Good afternoon, Madam Chair and Members of the committee sharing on behalf of the City of Carlsbad in support thank you.

Please go ahead. Line 183.

Good afternoon, Madam Chair and Members Ross. On behalf of the City of Coronado. In support thank you.

Line 201, you are open. And anybody else, go and hit 10. If you're in support or opposition to AB 40, please go ahead.

Michelle Warshaw, on behalf of State Superintendent of Public Instruction, Tony Thurmond in support.

Thank you.

Line 195, please go ahead.

Catherine Houston, on behalf of United Steel Workers District Twelve, USW local Twelve, 911, and USW local 1853 in strong support.

Thank you.

Clear the queue. Madam chair.

All right, thank you very much. Now be the time we'd bring it back to the committee Members. Thank you for bringing this forward and certainly one of the bills that sparked the most time and conversation in our committee. I want to thank the staff for all their work on this and you and the coalition for both sides on this. I'm going to support this today. I'm not quite sure what I'll do on the floor.

You've engaged in honest brokering and we've worked on this and made sure there was no teeth in this. I agree with a lot of opposition, and I've shared this before. I'm a caregiver two weeks ago. I spent a whole lot of time in the ER. And you really get to see what's happening, right? And the hospitals don't have any control over who's coming in. There was one person who was in the hospital bay.

The ambulance tried to pull out, and they stepped right in front of the car and came back in. So as people have said, it is a delivery system. I understand the frustration of the firefighters. I understand that. But at the same time, it is a full delivery system. You don't offer invitations to tell people to call you, and the hospitals don't extend invitations for people to come on in.

And I hope all the work that we've been doing these last few years, really trying to address behavioral health, really trying to address our substance abuse issues, really trying to address making sure that there are more providers out there so people are not using the emergency room as a first aid station. It makes it all very difficult. But I appreciate the work that you're trying to do here on this Bill, Senator Roth.

Thank you, madam chair. I want to join in. My thanks to the author for taking on this issue. I've served on hospital boards a variety of times, and back in the 90s when I was the vice chair of one board, wall time was a significant issue then. I returned to hospital boards twice in the 2000s between 2000 and 2012, and wall time was a significant issue then. It didn't seem to get any better.

And as we used to say in the military, what gets measured gets done. So sometimes you have to step up and do something in order for corrective action to be taken. But I do also understand that this is a very complicated issue. Certainly the hospitals and hospital administrators have a part to play in this.

But we worry here about the shortage of mental health beds in our communities and the emergency docs and the emergency departments are our psychiatrists in California now, and the emergency departments are our acute care sort of inpatient psychiatric facilities. So we're working on that. We also understand that, as has been stated, folks are coming to the emergency room even in ambulances with conditions that really don't belong in emergency rooms.

So others have been working on how to figure out a way to allow paramedics to triage cases and get the cases to the right location, which may very well not be the emergency Department clogging that up. And of course, we all know about the healthcare workforce shortages which existed before the pandemic and continue to exist and probably have been exacerbated by the pandemic. So it is complicated.

And so given all that and the role of the hospital in that, as this Bill moves forward I'm supporting it, by the way, in case you can't tell. As it moves forward, I hope you consider providing sort of an on-ramp for hospitals, because hospitals and lemses, as I read the analysis, are all over the place some lemses have plans, some don't. Some hospitals are doing well, some are doing mediocre, and some aren't doing much at all.

So perhaps instead of immediately implementing a 90% standard, maybe start at 70%, 80%, 90%, just give that some thought as the Bill moves forward. But I will be supporting the Bill today. And thank you for bringing the Bill. Thank you, Madam Chair.

Thank you.

Thank you, General. Senator Menjivar.

Thank you. As I remember, out of the 120 Members here, you and I are the only Members that understand Wall Time. Like you, I was an EMT for five years. I left in 2018 and it wasn't fun. Wall Time wasn't fun for me. So I 100% understand that part. But I also am on the same side of the General over there where I do have he is a General.

Once a General, always a General.

I was a General, absolutely. Where I do have some of those concerns, some of the questions that I have, and it's going to be a couple of questions. You mentioned the recommendations that came out of this stakeholder proposal. And I read that in this stakeholder proposals, there were CNA was there, emergency nurse representatives were there. And none of them voted for this recommendation.

And we're hearing from doctors on the other side, individuals who are on the other side of once we offload and hand the patient over, who see firsthand as an EMT. I remember how chaotic ERs as most of them were, and how I fear there could be rushed care. If our healthcare workers are saying that it's going to be a little difficult for us to do it. So that's a concern there.

I'm not sure how conversations have been going with emergency nurse representatives, with our nurse association, with doctors, so forth. And then in my district, I have a psychia I have a hospital that has both a regular ER and a psych ER. In the psychiars my wait times, there were ten times longer than a regular ER because we all have talked about the lack of psych beds all across the state of California. Would this Bill include psychiatrist?

Because I think that's really going to bring down the percentage for hospitals that have psychiatrist putting them under the same umbrella. So that would be my first question to you. And maybe we can go and answer and then I can go continue and ask other questions.

Well, right now the Bill is currently drafted. It's only for emergency rooms, but that is something we can work on. But that also is not including psych hospitals, just emergency medical your local Ed receiving hospitals. Well, for example, my hospital is a hospital. It's a hospital. It has two ERs. But that's for psych patients, correct?

No. One regular ER and one psych ER where only ambulances are allowed to drop off patients. So fire departments, private departments are dropping off patients there. Would they also be considered to be under the 30 minutes wait?

To the best of my knowledge, no. Just emergency departments only. Unless, Doug, you want to chip in on that. Maybe you might have better clarification center, if that's okay.

Through the chair. I think the language in the Bill is a general acute care hospital with an emergency Department. I think the facility in your district is LAC Olive Medical Center.

Correct hospital.

So the ED does have data within the ambulance patient offload time report from EMSA. I think we have to check if they roll the data from both EDs together or not because there is one line item in the MSA report for LAC Olive, so we're just going to have to look into that and happy to get back to you.

Okay, thank you so much for that. Like I mentioned, I left being an EMT in 2018. Maybe things have changed a lot in the City of LA. Correct me if I'm not using this terminology. Correct work 201 city. They're the ones who respond. They're their own ambulance, right? So I worked private ambulance. I did. IFTS inter-facility transport. Sometimes we also went to the ERs as well. We would get there and the fire departments, as they should, would trump all our calls.

So we would wait longer than the fire Department. Taking that into considerations. I know other areas like the areas that you worked at the private ambulances were the ones responding to each 911 call. Would there be a differentiation between those kind of public private ambulances and other private ambulances and 201? I see the gentleman over there shaking his head. Even all private ambulances, regardless if they're running 911 calls or not, are going to be under the 30-minute wait as well.

Correct. We're looking at as you're bringing the patient from a 911 call, right, for your closest ER receiving to get that patient off within 30 minutes. IFTS response is that's differently? Well, you know if you're going to run the IFT, right, you're picking up somebody from a skilled nursing facility to a local ER, right? Usually that's already been pre-approved by the hospital that, hey, we're receiving that patient because the facility contacted the hospital, hey, we need to bring this patient to the ER. So the hospital already knows well ahead of time that this patient is coming for whatever the case may be.

But it doesn't mean that they're going to see them at this point.

I don't think so. But unless Doug, you want to chip in. But to the best of my knowledge, no, I don't think so.

I will just stand. I think this Bill collects data specific to ambulance transports that generate from a 911 call. So I do not think while an IFT transfer between two facilities a crew may wait, I don't think that data is included in this current analysis or the analysis that's proposed by this Bill.

And while if it wasn't noted like the General, I'm also going to be supporting this Bill. But I just have a couple of these concerns and that makes me feel a lot better because I felt in IFT transports or ambulance companies that are for IFT they go to ERs as well. And I felt for them it was going to be extra hard for them to fall within the 30 minutes.

No, okay, yeah, I think I totally understand your point. Generally, those are planned transports. I think either the hospital may have a contract with the existing IFT provider or there may be another provider. But I don't think that data is out of a generated from a 911 call to a transport to the hospital. So, not an IFT. We will double-check, but I see.

That sounds like it needs some follow up.

We're happy to follow up, but I don't believe IFT is and if I.

Could just piggyback on that as well. So you got to know. So if you're doing IFT inter-facility transport so you're not really in the 911 system, right? Correct. So you're bringing that non-emergent, so to speak, patient to a hospital for more evaluation or workload. So that's not like you need that ambulance back on the road to respond to those 911. So that's a total separate category and.= that's why I brought that up, to make sure they weren't being grouped into this.

Yes.

Excuse me, do you have a question for her?

No, I just want to elaborate on so the whole purpose of the Bill is freeing up our first responders that are contracted on these 911 calls, the local fire departments, even the private sector EMS in some of these areas that the private sector EMS are the 911 providers. Right.

So we got to get them back on the roads because once we talk about the delays so if we can have all of our first in-unit, so to speak, tied up with some of these hospitals, the big delay is the backload when the other calls for service comes in. Now the closest ambulance to respond is not there because they're tied up. So are you going to be waiting 10-20 minutes?

So that's pretty much the main purpose of the Bill, get our folks back out there within 30 minutes. You got to remember the original part was 20 minutes. I've taken a lot of amendments. Now it's 30 minutes. And once again, I talk about that MSA task force, we talked about that and the majority of people present at those votings were vote for 20 minutes.

I know some of the doctors and nurses didn't really approve that, but the majority stakeholders in these meetings approved a 20 minutes timeline. But once again, I'm being flexible. We moved it to 30 minutes and we're just catering on our first responders to get them back out there on the roads because we're living in 2023. Is it right to hear we got a 2030 minutes response for an ambulance.

When we have it could be our loved ones, short of breath, cardiac arrest, traffic, no matter what it is. And we talk about hospitals taking a lot of the burden. Our private sector EMS folks, they're the ones holding the walls right now. They're also being innovative in community paramedicine. We're looking at alternative destinations. All of those things are being kicked around. So it's not just we're not doing anything, but just looking at hospital those they are doing things.

I would think a lot of our fire departments have nurses now on board running on some of these calls that, yeah, you know what, this patient doesn't need to go to the ER. They could better serve going back to their doctor or they can take care of the issue right there. So it's a lot of work in progress. But the main thing is, as I've stated before my opening, this has been going on for decades.

The pandemic may have made things worse, but it's been going on. Even Senator Raw talked about it in 2020, I think, or whatever, when you're on the board. This has been going on for decades. I personally, like I said, waited 12 hours 30 years ago and we haven't done anything about it. And we still want to try to delay or work on things.

We already know the data is there, but like I said, we've done a lot of work on this and this is just something that we need to try to continue the work in progress and come up with some standards. Right. And really, the flexibility is on the hospitals to help us develop these plans. We're not telling the hospital, you better do this or that. We're, hey, here's the tools, tell us how you can achieve that.

Because we all know some hospitals do a good job, they can get that patient off in 20 minutes. Because I've been in a lot of these hospitals, but others take their time for some reason. I don't know what it is, but everybody should be held accountable across the board.

Thank you. The rest of my questions were related to if it was going to impact those kind of ambulance companies. So if they're not, I think I'll put aside those questions. So I'll just end and I think the General suggested something that the ramping-up situation. I know it's 2023, but we never would have thought that there would be a pandemic as well. And not going to repeat everything about workforce shortage, but it's rates that we've never seen before.

But I'll yield my time, thank you very much. Seeing no other Members wishing to speak. And I'll just go back to my point. I mean, you said this is going to fix it, this is going to gather more data, right. This is not going to magically make a 30 minutes pod time, because if we could get there, I think we'd already be there. I don't think hospitals are just sitting around twiddling their thumbs. I've been in a lot of Eds.

Nobody's sitting around twiddling their thumbs saying, how can we mess with the ambulance people? Right? So we have a complicated system. Would you like to closer?

Well, with that, as I've said, I've been working on this issue for the last three or four years now. I've met with all the stakeholders, so nobody that's involved in this arena can say we're never part of any negotiations because my door has been open to everyone. How can we fix this problem? Because it's something that's going on for decades. And once again, I've been very flexible to take a lot of amendments. The first part was, like I said, the 20-minute implementation.

We moved out to 30 minutes now to give flexibility and let them know we want to work with you and all know that there is an issue. So once again, I just wanted to bring this forward again as a very important Bill, not just to myself, our first responders, but ultimately the people in the state of California. So with that, I respect the ask for an aye vote. Thank you.

Thank you very much. We'll see if we can get a motion when we get a quorum. Thank you very much.

Thank you.

Okay, so Assemblymember Bauer-Kahan you're up with AB 352.

Thank you, Senator. Thank you, madam chair Members. And thank you to the committee staff for your work on the Bill. As always, appreciate your efforts. I'm proud to present AB 352, a Bill to further protect reproductive rights by preventing information on abortion from crossing state lines. With Roe fully overturned, abortion access for 25 million women is either criminalized or highly limited. And that number only grows. We saw just this week Iowa pass a six week ban.

Though we did incredible work last year to protect abortion, access gaps remain. Specifically, physicians in anti choice states can easily see all the details of abortion care received here in California, even if it is unrelated to the patient's later health needs. This creates the risk that out of state providers will report patients to authorities and endanger both the patients and our providers. The last thing we want is for patients to face a trade off between criminalization at home or medical care here in California.

We must ensure that patients receiving abortion care in California don't have to fear a visit to their doctor when they return home. AB 352 prevents information on reproductive health and abortion in health information exchanges and other health systems from being automatically shared outside of California. This simple guardrail of consent will give patients the security and autonomy they deserve in their health care.

With me in support is Dr. Panelasi, a family medicine provider specializing in reproductive health, and Sophia Pedrazzo, counsel for Planned Parenthood affiliates who can answer any questions.

Thank you very much. First witness, please.

Good afternoon. Chair, Eggman and Members. My name is Dr. Pana Lassi, and I am a family medicine doctor and UCSF faculty who has provided and taught comprehensive community health care, including abortion, for the last 30 years. I came here from Sonoma County to support AB 532, I'm sorry, because I'm very concerned for my patients and my colleagues. The doctor patient relationship depends on trust, which in turn depends on confidentiality.

However, advances in electronic health record sharing, while very important, are creating serious confidentiality concerns. Most patients and doctors do not realize that medical records are now easily seen by other providers in the same electronic health system, even across state lines. I didn't realize it myself until a colleague who works in a small private practice here in California told me that she had provided a medication abortion for a patient who then went back to Texas and had to go to the emergency room.

My colleague got a notification through her electronic health record that the patient was seen in a Texas emergency Department. She could see the whole visit and realized that the provider that saw the patient in the emergency Department in Texas could also see her entire visit, that the Texas doctor could see that this patient had had an abortion in California. Currently, 20 states have banned or restricted abortion.

And so it is essential to ensure that when patients come to California to access abortion care, their sensitive health records will not cross state lines. Currently, large electronic health record companies share records with other doctors and providers that use their systems, even across state lines. I recognize the obvious benefits of the health information exchanges. It is a huge benefit to be able to see my patient's radiology report from the ER or the Rheumatologist's lab reports. These are important advances in our healthcare system.

However, in states where abortion is criminalized, this easy exchange of information exposes patients and providers to prosecutions and other state actions that are harmful to them. I facilitate a nationwide working group on this issue, and we have already heard about serious consequences from these privacy breaches. Colleagues have reported that patients travel from a state where abortion is banned to have a procedure in a state where it is legal, only to find that the electronic medical record of the procedure followed them back to their home state.

In one case, this resulted in a report to CPS. This patient is now dealing with the ramifications of being accused as an unfit mother for seeking a legal abortion. Some abortion providers have even resulted to using patient paper records rather than electronic health records to better protect patient confidentiality. I also volunteer on a hotline, a nationwide hotline for miscarriage and abortion.

And I have heard firsthand that patients are afraid that they might be turned in in their home states where abortion is banned because they sought abortion care in a state where it's legal. Right now, I cannot reassure these women that their medical records won't cross state lines and be seen by providers in their home state. This is an urgent problem. We need to act right now to make sure that sensitive medical information does not cross state lines.

We do not want to wait until someone is harmed before we do something in California to protect abortion patients and providers. These are real lives with real consequences. And California can continue to be a leader in the fight for reproductive freedom, but we must protect patient privacy. Thank you very much.

Thank you very much. Next person. Or are you just here for technical questions?

Just questions.

Okay. Thank you very much. Okay, others wishing to speak in support of this measure. Name and affiliation, please.

Good afternoon. Molly Robson with Planned Parenthood Affiliates of California, co-sponsor and strong support.

Thank you. Thank you.

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

Thank you.

Taylor Thompson on behalf of Lieutenant Governor Eleni Kunalakis. In support.

Thank you.

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

Thank you.

Karen Stout on behalf of the California Nurse Medical Association as well as NARAL Pro-Choice California in strong support.

Thank you.

Kathy Mossburg Essential Access Health In support.

Thank you.

Kiran Savage-Sangwan, California Pan Ethnic Health Network in support.

Thank you.

Noah Bartelt on behalf of ACLU California Action in support. Thank you.

Thank you very much. Okay, people speaking in opposition to this Bill today, first witness. Okay, seeing none. We'll go to the phone lines now. People speaking in support and or opposition to AB 352.

Madam Chair, as she stated, if you're in support or opposition to Assembly Bill 352, please press 10. And let's start with lane 208.

Madam Chair and Senators Michelle Teran-Woolfork with the California Commission on the Status of Growth in strong support. Thank you.

Thank you very much. Next caller.

And for any additional, please press 10. All right, Madam Chair, and we'll go to line 198.

Taylor Jackson with California Health Plus Advocates representing California's community health centers and support.

Thank you. Is that it Moderator ?

That's it.

Okay, thank you very much. Bring it back to the committee now. Questions concern. Okay, we don't quite have a quorum yet, but we will note that when we do get one. Wiener has moved the bill. Assembly Member, would you like to close?

Yes. Thank you, madam Chair and committee.

Actually, if I could just say, I just want to thank the author for her continuing leadership in this area. It's a multi year effort, so thank you.

Thank you, Senator. And I just wanted Senator Menjavar to ask to be added as a co-author, which I would be delighted to have. And with that, I respectfully ask for your Ivo.

Thank you very much. Thank you for carrying this Bill and presenting this today. Okay, I see Assembly Member Chen here jumping way up in the line but that's what happens, right?

Thank you so much, madam Chair, for the opportunity and letting me go a little bit ahead of everyone.

Yeah.

Again, thank you so much for allowing me to present AB 1283 today. Two years ago, the school board based allergies and asthma management program, HR. 2468 was signed into law. This legislation encourages all states to improve asthma care in schools by giving preference for federal grants to states that adopt certain asthma management programs and policies. While HR. 2468 does not require states to allow Ibuta roll stocking in schools, it would encourage schools to put it into place.

However, without state legislation, schools will be unable to receive any federal funding provided for them. Under the school based allergy and asthma management program, AB 1283 will allow access to federal funds to stock Ibutrol in California intending to treat children that have asthma attacks. At the same time, it will encourage education departments to provide emergency stock of Ibuterol inhalers if necessary, single use disposable holding chambers for school nurses or trained personnel who have volunteered.

The goal is to prove asthma care to help save the lives of children, all with little cost to the state of California. Here with me today we have witness testimony is Rakayla Medina representing the School Nurses in California.

Thank you. First witness, please.

Hi, good afternoon. Thank you to the chair and committee for allowing me to speak here today. I'm presenting to you here today as a nurse, a mother of two asthmatic children, a citizen of the valley, and an asthmatic myself in favor of this Bill. As a nurse, we are taught that adult patients suffer more frequently from cardiac related incidences, such as heart attacks. In the case of children, the respiratory system fails first.

This is exactly the scenario that happens to thousands of children in the valley every year. An asthma attack and two puffs of a rescue inhaler can prevent complete respiratory failure. I worked myself five and a half years at a level one trauma center in the central valley. It was not infrequent to see adults and young and old alike and teens from the valley in our emergency room or admitted to our facility following an asthma attack.

Unfortunately, due to long term COVID in some patients, in addition to a factory shutdown, a shortage of albuterol has created even more scarcity. AB 1283 can increase safety in our schools by having inhalers available when the need calls. As a child, I myself carried my own inhaler and was concerned for losing that inhaler because of the cost incurred if it was lost as a parent. Today, with high copayments, shortage of albuterol and other insurance issues, it's understandable why a child may have only one inhaler available.

As someone with a chronic condition, I also need to ensure that inhalers in our household are not expired and still have enough medication to give that life saving treatment. Doctors visits are required in order to achieve refills for our medication yearly. Personally, our primary care provider closed in 2020 in the middle of COVID In addition, my employer switched insurance, which caused my primary care provider to change six times within the last year.

Allowing this Bill to pass would allow kids on campus who possibly lose their inhaler or run out of medication to receive a potentially life saving treatment. As both a parent and a nurse, I would sleep better at night knowing that my children are protected if they are without their inhaler for any reason at school. Thank you to the committee as well as the chair for allowing me to speak on behalf of this initiative. I hope that I can receive your support.

Thank you very much. Everybody else, speak in support of this Bill today. Now's the time to come forward with name and affiliation.

Good afternoon, Madam Chair and Members. Alejandro Solis on behalf of Comite Civico Del Valle, representing AB 617, Community of Imperial County in support. Thank you. Thank you to the Assembly Member as well.

Good afternoon, chair and Members, Serette Kaminski on behalf of the Association of California School Administrators in strong support. Thank you.

Thank you. Okay, now we'll go to people speaking in opposition to this today, seeing none, we'll go to the phone lines. The phone lines.

You are in support or opposition, please press one. Filed by zero. And let's start with line 197. Please go ahead.

Kat DeBurgh with the Health Officers Association of California in support.

Thank you very much. Is there another one Moderator?

yeah, we have one more. If you're in support or opposition to AB 352, please press one followed by zero. And we have one queuing up with an operator. Just give us one moment, please. It all right. It's ready. Search 209, please go ahead.

Tim Gibbs, American Lung Association, in support.

Thank you.

And that does clear the queue. Madam Chair.

Thank you very much. Bringing it back to the committee. So remember, I think this is a fine Bill. I think our schools have turned into our line of first defense for our kids, whether it's mental health services, it's food, or it's medicine. As somebody who represents the valley and has an incredibly high rate of asthma, I'm appreciative of this Bill. Would you like to close?

Madam Chair, thank you for your leadership and your kind words. I respectfully ask for aye vote.

Thank you very much. We'll get a quorum at 1 point.

Thank you, Madam Chairman.

Thank you very much. Okay, and calling all Health Committee Members. I know there's a lot of you out there and I know everybody's busy, but be great if we can get a quorum. Did Mr. Gabriel give you permission to all right, we have a guest presenter, Senator Wiener, presenting for Assemblymember Gabriel item 1512.

There's two of them. Twelve and 13.

Fantastic.

Thank you, Madam Chair. I'm here presenting item twelve, AB 1063, on behalf of Assemblymember Gabriel, who is ill and sends his regrets for not being able to be here today. AB 1063. First of all, I want to, on behalf of the Assembly Member, accept the committee's amendments and the analysis. AB 1063 is a straightforward accountability measure that will require the Department of Public Health to officially document the effectiveness of its efforts to enforce nurse staffing ratios in hospitals and health facilities.

In particular, documenting its enforcement of existing regulations, including data regarding the number of complaints received and the investigatory steps taken in response to those complaints. The Bill will also require CDPH to receive input from healthcare professionals about ways to improve its enforcement, thereby giving healthcare workers a voice in the process. And so doing, AB 1063 will provide greater transparency and accountability to make sure that the laws we have passed in this building over the years for nurse staffing ratios are actually being enforced.

I respectfully ask for an aye vote. With me today to testify are Charmaine Morales, a registered nurse and President of UNAC, UHCP, as well as Matt Lege, Government Relations Advocate for SEIU California.

Thank you very much. First person in support of six minutes total per side.

Hi, I'm speaking on behalf Charmaine Morales, my name is thank you Chair Egman and Members of the committee for considering AB 1063 and thank you Senator Wiener for your support. My name is Sandy Marquez and I have been a registered nurse for approximately 39 years in critical care inthe Cath Lab IR, and I am a Member of the United Nurses Association of California Union of Healthcare Professionals.

AB 1063 requires the Department of Public Health to officially document the effectiveness of its efforts to enforce nurse staffing ratios title 22 in hospitals and health facilities, leading to greater transparency and accountability. Nurse to patient ratios became law in California to protect patients as well as to support RNs and facilitate the delivery of safe patient care.

Unfortunately, the chronic noncompliance with Title 22 and the staffing ratios has led to burnout, fatigue and an increase in the number of nurses leaving bedside nursing nursing altogether or retiring sooner than anticipated. Nurse burnout is a significant problem and according to the CEO of the University of Pennsylvania Health System and extensive research data, safe staffing standards will help relieve and prevent nurse burnout, create better improved work environments to attract and retain dedicated frontline registered nurses.

But most importantly, it correlates with improved safe patient care and improved outcomes. Many of our staffing challenges, specifically understaffing existed prior to the COVID Pandemic COVID only exacerbated the problem more and highlighted the issues. The staffing crisis has taken a heavy toll on our nurses and the failure to staff appropriately results in higher levels of nurse burnout and nurse turnover. Acute care hospitals rely on the experienced nurses to train, teach and support the new nurses on their knowledge.

Journey out of ratio staffing makes this nearly impossible. Understaffing has also led to unnecessary costs to the employer. Hospitals have spent millions of dollars on travelers instead of hiring permanent nurses. Hiring these temporary RNS, sometimes from other states, costs much more than a regular nurse on an hourly basis. Additionally, high levels of temporary staff negatively impacts the employer's ability to educate and develop consistent improvement to safe patient care and good patient outcomes.

Moreover, AB 1063 will allow direct cared nurses to provide input regarding the efficacy of CDPH's enforcement efforts as well as suggestions for improving enforcement. The Bill does not impose any new obligations on hospital, nor does it impose any fines, but it does ensure that CDPH's enforcement efforts regarding existing laws are effective, transparent and promotes accountability, which doesn't happen now.

If you file a complaint and then you try and follow up with CDPH, you cannot get any responses even when you have proof that what they believe occurred in the hospitals didn't occur. Thank you for your time, and I respectfully ask for your yes vote. Thank you.

Thank you very much. There's another major witness. Go ahead.

Madam Chair Members. I'm clearly not Matt Lagere, but Sara Flocks, California Labor Federation. We are in support of the Bill, and this committee and lawmakers have passed groundbreaking laws to protect patients and workers. But those laws only are effective if they're enforced. This is a very simple Bill to increase transparency, to make enforcement more effective. When we find transparency does that, which is incredibly important post pandemic, when we really need to make sure we have enough healthcare workers, frontline healthcare workers, and are protecting patient safety. So we urge an aye vote thank you.

Thank you very much. Okay, now's the time for others just speaking in General support. Name and affiliation?

Good afternoon chair Members. James Michael Powell with AFSCME California in strong support. Urgent. aye vote thank you.

Thank you very much. Anybody else speaking in support of this today? Okay, seeing none. Anybody speaking in opposition to this today?

Good afternoon, chair and committee Members. Vanessa Gonzalez with the California Hospital Association, here in opposition to AB 1063. While we do appreciate the committee amendments, CHA does remain in opposition to the legislation. As you know, Senators, California is in the midst of a healthcare workforce crisis. A recent study by UCSF found that California had a deficit of 40,000 registered nurses in 2021, and that number has likely only grown. At the same time, hospitals are experiencing unprecedented patient volume, a 42% increase in the last seven years.

Still, hospitals are doing everything that they can, everything in their power to ensure that staffing ratios are being met, including hiring travel nurses when there are not enough typically employed nurses to meet the demand. Cha is also sponsoring and supporting proposals to increase the nursing pipeline. Given the workforce crisis and record patient volume, now is not the time to require additional reporting requirements that are largely duplicative of current state law and will not result in improved patient care.

Importantly, there is already a process in place for anyone to file a complaint on staffing ratios, and CDPH enforcement actions on facility compliance are already publicly available. We are also concerned that AB 1063 would result in an increase in unsubstantiated staffing ratio complaints, as well as staff time being pulled away from patient care to assist CDPH in investigating those complaints. For these reasons, Cha remains in opposition to AB 1063. Respectfully request your no vote. Thank you.

Thank you very much. Others speaking in opposition to this Bill today? Name and affiliation? Seeing none. We'll go to the phone lines. Anybody speaking in support and or opposition to AB 1063?

Madam Chair, as she said, if you're in support or opposition to AB 1063, please press 10 one followed by zero. And we'll start with line 195.

Please go ahead.

Catherine Kingston United Steel Workers District Twelve in strong support.

Thank you.

And a quick reminder, one followed by zero if you're in support or opposition to 1063, and we have no other participants queued up at this time.

Okay. Bring it back to the committee, Senator Roth.

Thank you, Madam Chair. You know, I appreciate the hospital's concerns about this. I do think sunshine is a good thing, particularly where we have government and we have rules that were put in place. Somehow, we as a Legislature need to review how the rules are working. And I do appreciate the amendment that was taken to make this a full and open discussion.

Not just the very important direct duty nurses who have issues or may have issues with the staffing ratios, but other players and stakeholders in the process, so there can be a robust conversation about the staffing ratios, how they're working, how they're not working, and a report generated in a format that we as legislatures, legislators, can review. So with that, I will be supporting the measure today and thank the author for taking that amendment. Thank you, Madam Chair.

Thank you very much. And you did accept the amendments on behalf of the author. Okay, thank you. And I will associate my comments with Senator Roth and also much like my comments on Mr. Rodriguez's AB 40. If we had a magic wand and create all kinds of new healthcare professionals, that would be fantastic. I think that is the work of our generation, is to really address our workforce crisis across industries, but especially as it relates to healthcare and behavioral health care.

We have an incredible crisis, and as the General said, this will shine more light on it. And there's no repercussions for the hospitals at this time as we all continue to work to address this crisis. Would you like to close, sir?

Ask for an aye vote.

Okay. Would you like to carry on? As the Assembly Member.

I'll continue to play the role of Jesse Gabriel. So I'd now like to present Assembly Bill 1217 again on behalf of Assembly Member Gabriel. We'll be accepting the committee's technical amendment to add Senator Rubio as a co author. AB 1217 will continue work that actually Mr. Gabriel and I did together a few years ago to make permanent the Pandemic outdoor dining rule, which is very positive. We saw during the pandemic that outdoor dining flourished, and much of it has remained.

And we want to make sure that these restaurants can actually serve not just food, but also alcohol outdoors. The Governor signed our bills to do that, and we want to extend it and keep it going, have vibrancy in our public spaces and support our small restaurants. And I respectfully ask for an aye vote. With me today to testify is Matt Sutton with the California Restaurant Association.

Mr. Sutton.

Thank you, Madam Chair. Thank you, Senators. Thank you, Senator Weiner. Matt Sutton with the Restaurant Association. This is an extension of existing law. If you're wondering why it's in your committee. The piece that deals with the jurisdiction of the Senate Health Committee is the piece that allows for light food preparation on portions of restaurant expansions that are not contiguous necessarily, and are not on the restaurant site.

So some of these are the new creative aspects of dining that have taken place and that are sticking around in a lot of neighborhoods. This allows that light food preparation over in the non contiguous space as long as the restaurant itself is permitted for such food preparation. So we'd ask for your aye vote and thank you for your support.

Makes sense. Thank you very much. Anybody else speaking in support of this Bill name and affiliation?

Good afternoon. Sarah Necito on behalf of the United Chamber Advocacy NetworkIn support in support.

Thank you, Sarah. I see no other people approaching the Mic people speaking in opposition to this Bill today. Seeing none. We'll go to the phone lines. Moderators or anybody in the phone lines.

Our queue, ladies and gentlemen, we should speak in support or opposition, please press one and zero at this time. We'll be going to line 214. Please go ahead.

Emellia Zamani on behalf of the California Travel Association, in support.

Thank you very much. Next caller.

There's currently no one else.

Thank you very much. Bring it back to the committee. Senator Nguyen.

I just want to say. Thank you to you for presenting also to the Assemblyman for putting forward this. And when it's appropriate, I would like to move it.

Thank you.

Okay. Would you like to close, sir?

Respectfully ask for an aye vote.

Thank you very much. Fun Bill. No workforce issues. Restaurants can just close if there's a workforce issue. Okay. Assembly Member Bonta, I see you. Item nine, you're presenting today, AB 722.

Thank you so much, Madam Chair and committee Members. Alameda Health System is a public hospital authority which administers and serves hospitals in Oakland, Alameda and San Leanne Drew. Currently, Alameda Health System cannot contract out the services provided by unionized physicians without evidence that doing so will be cheaper and more efficient. This requirement will sunset on June 1, 2024. AB 722 extends that sunset to January 1, 2035. Here today to testify on behalf of the Union of American Physicians and Dentists, ask me, Local 206 is George Osborne.

Thank you very much, Mr. Osborne.

Thank you, Madam Chair. Members. Good afternoon, George. Osborne. I'm a contract advocate for UAPD AFSCME Local 206. Want to thank Assemblymember Vanta for bringing this Bill forward, which extends from January 1, 2024, to January 1, 2035. The limitation on contracting out to replace services being provided by our Members at UAPD. After years of legal action under the current system, Alameda Healthcare System and UAPD had developed a good working relationship.

As Bert Lance said when he served as President carter's Director of OMB, if it ain't broke, don't fix it. There is no known opposition to AB 722. We respectfully ask the committee, allow the hospital system and our Members at UAPD to continue to work together thank you very much. And respectfully request an aye vote.

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

Afternoon. James Michael Powell with AFSCME. California proud co-sponsor. Urgent. aye vote. Thank you.

Thank you very much. Okay, now we'll go to people in opposition. As Mr. Osborne said, there is no opposition. Is there anybody on the phone lines who wishes weigh in on AB 722?

Ladies and gentlemen, if we should speak in support or opposition, please press one and zero at this time. There's currently no one queuing up at this time, madam Chair.

All right. Would you like to close on this Bill that did not generate hours and hours of discussion with our committee?

Well, thank you. And this Bill has enjoyed unanimous bipartisan support and I hope to continue that streak in this committee today. And I respectfully request your vote.

Thank you very much. At some point, we'll get a quorum. Okay. Seeing no other Assembly Members here to present, we'd like one prices. The price is right. Come on down. Yeah. Thank you. Okay. You are presenting today item, file item 19, AB 1451.

Yes, ma'am. Thank you very much. Madam Chair, Members of the Committee, AB 1451. I want to start out to thank the staff for working on this Bill, to continue to improve it. And I'm glad to accept and agree to the amendments. As many of you are fully aware, we are in the midst of a mental health crisis.

In fact, according to the Department of Psychiatry and Behavioral Sciences at University of California, Davis, as many as 40% of patients seen in primary care have an active psychiatric condition. And as found by the California Healthcare Foundation's 2022 Report on Mental Health in California, one in seven California adults experience mental health illness and one in 14 children has an emotional disturbance that limits functioning and family, school, or community activities.

The severity and duration of this crisis is and will continue to be about our ability to bring timely access to quality mental health treatment to everyone in need. And that is why AB 1451 is here to ensure that those suffering from a mental health illness or in need of treatment can receive timely treatment.

We know that by common practice and the science and, of course, social workers are always taught, once you have somebody, give them everything you can while they're there because the chances of them coming back is slim. And this Bill ensures that when someone goes into a hospital, that they are able to receive both physical and mental health at the same time.

And this is done by making sure that healthcare service plans provide reimbursement for services provided and to be in compliance with the requirement for timely payment of claims. Importantly, this Bill shall only be implemented upon appropriation by the Legislature specific to administrative cost for the Department. This also makes sure that treatment has no barriers as regards to pre-authorization.

And so when doctors see that a mental health services need to be rendered, we want to make sure that there is no barrier between their doctor and their patient to receive the mental health treatment that they can. Just like the various other crises that California face, we know that we have to then knock down every silo, every barrier possible to ensure that people get the help that they need. And so I respectfully ask for an aye vote.

Thank you very much. Okay, people speaking in support for this measure today?

Apologies, I wasn't sure if there was a lead witness, but Priscilla Quiroz here on behalf of a few clients, California Academy of Child and Adolescent Psychiatry, California State Association of Psychiatrists, and the California Faculty Association, all in strong support.

Thank you very much. Next person, please.

Thank you, Chair members. So Jose Torres with Health Access. I wanted to say that we are in a support if amended position, but do thank the committee and the author for working with us on the amendments to limit the upon appropriations language and ensure the Bill is consistent with recent behavioral health laws passing the Legislature. But we do look forward to continuing the discussions.

Thank you very much. Okay.

Mark Farouk, California Hospital Association, in support.

Thank you very much. Okay, anybody speak in opposition to this Bill today? Time to come forward. Okay, seeing none, we'll go to the phone lines. Anybody in the queue?

If you wish to speak in support or opposition, please press one, then zero. At this time. We'll be going to line 198. Please go ahead.

Taylor Jackson with California Health Plus Advocates, in strong support.

Thank you very much. Next caller, please.

Someone has just queued up. Wait one moment while they are given their line number. Next we'll go to line 177. Please go ahead.

Hi, Megan Chung on behalf of the Steinberg Institute and the Kennedy Forum with the forthcoming amendments, we're happy to move from support if amended to support. Thank you to the author and the committee for your partnership.

Thank you. Next caller, please.

There's currently no one else in the queue at this time, madam.

Okay, thank you. Bringing it back to the committee. Okay, no questions, concerns. We thank you for bringing this forward. I know you want to treat mental health like the emergency it is, and I appreciate you putting words to that idea. And also thank you for accepting the committee amendments. I know you worked a lot on those. Would you like to close, sir?

I respectfully ask for an aye vote.

Thank you very much. When we get a quorum, hopefully soon, we will see if we can get a motion and take that.

Thank you very much.

Okay, thank you very much. I'm very hopeful we'll get a quorum.

Hello, Assemblymember. You want to come on over? Can somebody get Senator Wiener in the side room?

We're almost to a quorum. Okay. Are you all settled? You need a minute? You're okay? All right.

It's been a long day.

Amen, sister.

Amen, sister. Okay. Thank you, Madam Chair and senators. I would also like to thank the committee staff for their work with us on this Bill. AB 420 clarifies that the Medicinal and Adult Use Cannabis Regulation and Safety Act does not prohibit a cannabis licensee from manufacturing, distributing, or selling products that contain industrial hemp or hemp-derived compounds or extracts.

This Bill also contains needed cleanup language that will help protect the public from adulterated hemp products which are already illegal but can still be found across the state. Hemp and Marijuana are both members of the cannabis family, but hemp is legally regulated to not be intoxicating and has higher levels of CBD. Given the similarities, many of the products made using hemp and cannabis are manufactured using similar processes, and the products are similar too.

For example, CBD products can be made from hemp or cannabis and are very popular among consumers. CBD is nonintoxicating or habit-forming, and provides relief from pain, inflammation, anxiety, insomnia, and other conditions. CBD products derived from hemp are widely available online in grocery stores, gas stations, gyms, and other common retail locations. However, CBD is also used in many cannabis products, but cannabis manufacturers, distributors, and retailers can only work with cannabis-derived CBD.

Cannabis-derived CBD is much more expensive because it is subject to stricter regulation and cannabis typically has a lower CBD content. This puts our cannabis licensees at a disadvantage when selling their products. This restriction contributes to the struggle of cannabis licensees to stay afloat as they compete with the illegal market. AB 420 will enhance the viability of legal cannabis licensees in the marketplace by authorizing licensees to manufacture, distribute, and sell hemp and hemp-derived CBD and other products in compliance with current law.

We look forward to working with stakeholders, state agencies, and committee staff as we address concerns about the best way to implement these changes. We are especially committed to further empowering our state regulators to attack the production and sale of illegal synthetic chemicals in the marketplace today. With me today are Pamela Epstein representing the California Cannabis Industry Association and Caren Woodson from Kiva Confections. Welcome.

If you could hold on 1 minute. We're going to establish a quorum. Secretary, please call a roll.

Senators Eggman. Eggman, here. Nguyen. Nguyen, here. Glazer. Gonzalez. Gonzalez, here. Grove. Hurtado. Hurtado, here. Limon. Menjivar. Menjivar, here. Roth. Roth, here. Rubio. Wahab. Wiener. Wiener, present.

Thank you very much. Okay, go ahead. And we have a quorum.

Excellent. Thank you Chairwoman Eggman and members of the committee. Thank you, Assemblywoman Aguiar-Curry for the leadership. Again, that brings us here today. My name is Caren Woodson for Kiva Confections, and I'm also here on behalf of the California Cannabis Manufacturers Association to urge your support for AB 420. In addition to strengthening the enforcement provisions, I am here to testify that manufacturers like Kiva would benefit greatly by the option to use hemp-derived cannabinoids in our products.

A significant number of Kiva's products use minor cannabinoids like CBN and CBD to create a tailored experience for our consumers. But it's costly to source these minor cannabinoids from the closed loop cannabis market, and those costs are rising as we start to see contraction in the cultivation sector. According to Kiva's innovation team, a product made with hemp cannabinoids would, on average, cost around $20, but that same product, sourced from cannabis-derived cannabinoids, cost consumers about $24.

So there's about a 20% savings that could be passed on to the consumers and help make the product a little bit more competitive against the illicit cannabis market. In addition to integration, we support efforts to increase the enforcement against proliferation of intoxicating hemp products. AB 420 represents a step in the right direction, and I strongly urge your support today. Leave it over to my colleague, Pamela.

Thank you very much.

Good afternoon, Chairman Eggman and the rest of the committee. And again, thank you to the Assemblymember Aguiar-Curry for leading the charge on this profoundly important issue. My name is Pamela Epstein. I'm the chief legal officer for Eden Enterprises and the President of the California Cannabis Industry Association. I'm here to express my support for AB 420, a Bill that strengthens enforcement of AB 45 and promotes the integration of hemp cannabinoids into the regulated cannabis supply chain.

As noted in the analysis, the Department of Cannabis Control's Hemp Report, which was delayed by six months, failed to provide the specific framework for the inclusion of hemp into the cannabis marketplace, as was directed by AB 45, and unfortunately offered a general contrast of hemp and cannabis regulations. With the regulated cannabis industry in crisis, integration is imperative for the following reasons. Integration of hemp cannabinoids will benefit the overall supply chain, as we've heard.

Minor cannabinoids are in short supply and they drive up costs to the consumers. Manufacturers already produce CBD only products, low dose products, and max potency products in the same facility. The DCC has not issued any statewide recalls due to the mislabeling of potency between CBD and THC. Incorporating hemp is similar to incorporating any other ingredient into the cannabis product and will be taxed and quality assurance tested the same way.

Integration maximizes the facility utilization, reduces costs, and fosters innovation, making the industry more capable of competing with the illicit market. Second, integration promotes and protects public health and safety. The lack of enforcement has allowed the proliferation of these intoxicating hemp products, posing severe health and safety risks. Consumers are offered unregulated, untested hemp products that are three to 33 times stronger than that of legal cannabis.

This is why the Cannabis Regulators Association wrote to Congress urging federal action to regulate intoxicating hemp-derived cannabinoids, of which the Department participates and Nicole serves currently as a member at large for CANRA. Rogue intoxicating products have caused estimated losses for dispensaries as high as 30% and growing.

While the regulated industry mandates track and trace quality control assurance testing, intoxicating hemp products are often designed to be attractive to children and are manufactured using heavy metals and residual solvents with unenforced testing requirements. Integration in California will be unable to participate without integration. California will be unable to participate in interstate commerce.

The Governor and the Department supported interstate commerce with the passage of SB 1326 last year, and subsequent to that, a State Attorney General's opinion regarding the legality of interstate commerce. But without integration, California's regulated industry will struggle due to high production costs and excessive fees compared to other regulated markets. To lead the California Cannabis conversation and remain competitive, we must allow for integration.

For these reasons, CCIA proudly supports 420 and looks forward to collaborating with the author and other stakeholders to address outstanding issues, including testing parity per package and per serving caps for edible hemp products, and further limitations on the production and sale of uber potent synthetic cannabinoids. I urge you to vote aye today. Thank you.

Thank you very much. Anybody else speak in support of this Bill? Name and affiliation?

Madam Chair and Members, Rand Martin on behalf of the Parent Company, in support. Thank you.

Thank you.

Talia D'Amato on behalf of California NORML, in support.

Thank you.

Amy Jenkins on behalf of CannaCraft, in support. Thank you.

Thank you very much. Okay, anybody speak in opposition to this Bill today? Now's the time to come forward.

Hello again. Madam Chair, Members. I'm Dr. Lynn Silver, pediatrician, Senior Advisor at the Public Health Institute, and clinical professor at UCSF. AB 420 fails to solve the key problem of our state's initial hemp framework while introducing new ones. A good part of the Bill is the prohibition on the dangerous group of new artificial and intoxicating cannabinoids created through chemical modification of CBD, compounds that have been massively marketed with no assessment of human safety and growing evidence of harm, including mental illness and poisonings.

Two weeks ago, CDPH finally clearly determined that these are products of chemical synthesis illegal under existing law, but AB 420 will provide further clarification of their illegality. However, it fails to create the most urgent missing piece in hemp regulation. The hemp industry has massively flooded markets with highly psychoactive and intoxicating products, exploiting the notorious 0.3% THC farm build loophole. We warned of this here two years ago.

Many hemp edibles have far more traditional Delta Nine THC than legal cannabis edibles may contain, and are now widely sold and available to be sold to ten year olds in corner stores near schools across our state. Go in any smokeshop and you will see a four-year-old in West Virginia recently died after ingesting intoxicating hemp candies. We join with many cannabis industry colleagues in demanding action to keep kids safe by prohibiting intoxicating hemp products now.

AB 420 opens the cannabis industry wide to hemp, including these intoxicating compounds, discarding guiding principles of Proposition 64 and undermining some legal cannabis cultivators hard hit by the illicit market. Rather than a thoughtful process of integration, products merely need to comply with current hemp law. So it will create a parallel set of untaxed products in cannabis retailers with weaker product packaging, warning, and marketing protections, including unattractiveness to children than cannabis currently has.

And it will, without a cap, will allow edibles with far more THC than legal cannabis edibles to continue to be widely available now, including in cannabis retailers. It will further reduce cannabis tax revenues and its critical flows to childcare slots, youth substance abuse prevention, and enforcement.

For these reasons, we respectfully urge your nay vote, unless amended, to add a prohibition on intoxicating hemp final products with more than a milligram of THC per package, and deletion of the chaotic and untaxed opening of cannabis retailers to hemp. There will be a path to more sensible integration in the future, but that this is not yet offering that. Thank you.

Thank you very much. Anybody else speaking in opposition today? Now name an affiliation. We go to our phone lines.

Ladies and gentlemen, if you wish to speak in support or opposition, please press one, then zero at this time. There's currently no one queuing up at the time, Madam Chair.

Okay, thank you. We'll come back to the committee, and I guess I'll just say to the opposition, I want to thank you for your leadership in this. I was there a couple of years ago when we started this, an hour back. But it does sound like there's some more legislation that needs to be done.

Perhaps an amendment going into approps and or a piece of work that you can work on next year to be able to address this kind of unaddressed issue that your Bill doesn't talk about this, but it's just another part that I think is part of the picture.

That's fair, is that one of the things that we were waiting for is the hemp report, and it didn't come out for seven months. And so we're trying to make sure we patchwork this, because in the meantime, we have a lot of issues that we need to take care of, and we will continue to do that. So I've been working with the stakeholders to examine questions that it's raised, and we're getting close to trying to have an answer.

But again, with that hemp report not coming out in a timely fashion, we can't continue to wait, and we needed to take some action now. So is it a lot more work we can do? Absolutely. Does it have additional work maybe in the future? Probably.

Okay. And did you pick this number or did one of your clever staff?

I have a very clever staff.

Okay. I thought so. Okay, thank you very much. Anybody else? How about a motion?

When I looked at this as a member, three of us here took action this year in sub-three related to more funding to CDPH on this very specific thing because they were having trouble finding hemp manufacturers. And I read this as saying, oh, this brings it into something that's already being regulated that is going to be easy to find. I saw this as a step forward in helping regulating hemps, if I read this correctly. So happy to move the Bill forward.

Okay, thank you. Thank you. Would you like to close?

Yeah, I would like to close. First of all, thank you very much for acknowledging that. This bill's passed out of the Assembly. But we have taken amendments to address many of the opposition's concerns in keeping synthetic chemicals out of the hemp products and to help give DPH more authority over products coming into our state. I have been working with these issues for five years. We know that and this is always evolving, and we're going to have to continue to work on this.

As I present this Bill to you today, it will make products and practices safer, make it harder for criminals to sell illegal products, but that doesn't mean our work is done. I assure you that I will continue to work with all the stakeholders to implement integration in a way that supports our legal hemp and cannabis industries, empowers our regulators to attack illegal products, protects public health, and I commit to you that I will update you as we move forward. And I appreciate your aye vote.

Thank you very much. Okay, we have a motion, and the motion is due pass, and we refer to the Committee on Appropriations. Secretary, please call the roll.

Senators Eggman. Eggman, aye. Nguyen. Glazer. Gonzalez. Gonzalez, aye. Grove. Hurtado. Hurtado, aye. Limon. Menjivar Menjivar, aye. Roth. Roth, aye. Rubio. Rubio, aye. Wahab. Wiener.

Six will hold that roll open. Thank you very much. It's 3:25 p.m. Get a motion on the consent calendar.

Senator Rubio made that motion. Wendy said, Wendy called the winner. Please call the roll. And this is on the consent calendar was AB 614, AB 820, AB 1202, AB 1478, and AB 1612.

Senators Eggman? Eggman aye. Nguyen? Glazer? Gonzalez? Gonzalez aye. Grove? Hurtado Hurtado aye. Limón? Menjivar? Menjivar aye. Roth? Roth aye. Rubio? Rubio aye. Wahab? Wiener?

All right, at six we'll hold that roll open. Let's move on to AB 4, Arambula, if we can get a motion on that, so moved by Senator Menjivar. That's on AB 4 and that is the motion is do pass as amended and refer to the Committee on Appropriation. Secretary, please call the roll.

Senators Eggman? Eggman aye. Nguyen? Glazer? Gonzalez? Gonzalez aye. Grove? Hurtado? Hurtado aye. Limón? Menjivar? Menjivar aye. Roth? Roth aye. Rubio? Rubio aye. Wahab? Weiner.

6-0, we'll hold that roll open. Moving on to file item number two, AB 40. If we can get a motion by Senator Roth that is do pass and refer the Committee on Appropriations. Secretary?

Senator Eggman? Eggman aye. Nguyen? Glazer? Gonzalez? Gonzalez aye. Grove? Hurtado? Hurtado aye. Limón? Menjivar? Menjivar aye. Roth? Roth aye. Rubio? Rubio aye. Wahab? Wiener?

60. We'll go on to AB 352 Bauer cahan moved by Senator Menjivar that is do pass and refer to the Committee on Appropriations. Secretary.

Senators Eggman? Eggman aye. Nguyen? Glazer? Gonzalez? Gonzalez aye. Grove? Hurtado? Hurtado aye. Limón? Menjivar? Menjivar aye. Roth? Roth aye. Rubio? Rubio aye. Wahab? Wiener.

6-0. Moving on to file item number nine, AB 722 by Assemblymember Bonta. The motion is do pass. Have a motion? So moved by Senator Roth. Secretary?

Senators Eggman? Eggman aye. Nguyen? Glazer? Gonzalez? Gonzalez aye. Grove? Hurtado? Hurtado aye. Limón? Menjivar? Menjivar aye. Roth? Roth aye. Rubio? Rubio aye. Wahab? Wiener?

Magic number six again. All right, moving on to AB 1063 by Gabriel So, moved by Senator Roth. That motion is do pass as amended and referred to the Committee on Appropriation. Secretary?

Senator Eggman? Eggman aye. Nguyen? Glazer? Gonzalez? Gonzalez aye. Grove? Hurtado? Hurtado aye. Limón? Menjivar? Menjivar aye. Roth? Roth aye. Rubio? Rubio aye. Wahab? Wiener?

6-0 again. Moving on to file item 13, AB 1217 by Senator Gabriel, Cervantes and Schiavo. That motion is do pass as amended and refer to the Committee on Appropriations, moved by Senator Nguyen, who wanted to be a co-author. Secretary, please call the role.

Senator Eggman? Eggman aye. Nguyen? Glazer? Gonzalez? Gonzalez aye. Grove? Hurtado? Hurtado aye. Limón? Menjivar? Menjivar aye. Roth? Roth aye. Rubio. Rubio aye. Wahab? Wiener?

6-0, I guess. Okay. Oh, that's right. File item 16, Assemblymember Chen. Motion is due pass and refer to the Committee on Appropriations, moved by Senator Menjivar. Secretary, please call the role.

Senator Eggman? Eggman aye. Nguyen? Glazer? Gonzalez? Gonzalez aye. Grove? Hurtado? Hurtado aye. Limón? Menjivar? Menjivar aye. Roth? Roth aye. Rubio? Rubio aye. Wahab? Wiener?

Still 6-0. Okay, looking for authors. Oh, yeah, that's right 19, Jackson, that's right. People who have been here the whole time will get out a little bit earlier. We'll get through all of these. Not that it's anybody's fault. Do pass as ammended, refer to the Committee on Appropriations, moved by Senator Wahab. No, Menjivar. Please call the roll.

Senator Eggman? Eggman aye. Nguyen? Glazer? Gonzalez? Gonzalez aye. Grove? Hurtado? Hurtado aye. Limón? Menjivar? Menjivar aye. Roth? Roth aye. Rubio? Rubio aye. Wahab? Wiener?

6-0.

Assembly Member Wood. You win, you get the prize. People have been so happy to see you since you were making dinner or something.

Okay, madam Chair, I'm so happy to see you have such a large contingent of your committee.

We had more. We were sitting, waiting, seeing people laugh. They drift.

I know. I understand that one completely.

Okay. And if I can just say to Health Committee Members, we have an author, so now would be the time to come on back. Assembly Member Wood. Oh, now we have two authors. Okay. We're rich. AB 843. Do you want to start with that one for Mr. Muratsuchi?

You mean 483?

483. Sure. That's what I mean, too.

Okay, well, how about if we do that? Thank you. Thank you. Madam Chair and Members. On behalf of Assembly Member Muratsuchi, I am the bill's joint author. Before I begin, I want to confirm we are happy to accept the committee's suggested amendment on page seven of the analysis and thank the committee and staff for their work on this Bill. This is a technical but important Bill that will increase access to school based health and mental health services.

The Lea Billing Option Program allows schools to be reimbursed for medically necessary services provided to any Medi Cal eligible pupil by school health professionals. For too long, the Department of Healthcare Service audit process has been a barrier to increasing access to these school based services. Schools have been frustrated with the heavy administrative burden and punitive audit findings. Many districts have faced significant disallowances requiring them to return money to the state. And as fiscal risk has discouraged participation, schools have dropped out of the program entirely.

And some don't Bill for the services that are eligible for reimbursement. In fact, 75% of Lea claims audited between 2007 and 2015 required some level of repayment to the state. And during that time, not a single Lea won a formal appeal. Repaying claims means that schools are dipping into their General Fund, taking funding away from classroom and other services to students. As a result. Currently, only about one half of the LEAs in California participate in this program.

So we are leaving significant federal money on the table. AB 483 requires reforms to the auditing process to increase timeliness, ensure all eligible services are reimbursed, and provide additional technical assistance. These changes will encourage more schools to participate in the Lea Billing program, bring more federal money to our state, and ultimately increase the availability of critically needed health and mental health services on our school campuses.

I have two witnesses here today with me Derek Lennox, representing the California County Superintendents Association, and Tony Trigueiro with the California Teachers Association.

Thank you very much. Please begin.

Thank you, Madam Chair Toni Trigueiro on behalf of the California Teachers Association and one of the co sponsors of AB 483, it accomplishes three things it maximizes the number of local educational agencies participating in the LEA BOP program, which, as the Assembly Member indicated, has about a 50% participation rate at this point.

It draws down the maximum amount of federal dollars that California is eligible to receive and it delivers to students both the physical and behavioral health services they're entitled to. Prior to July 2020, only California students with IEPs, Individualized Education Plans, were eligible to receive LEA BOP services. But as of July 2020 and retroactive to 2015, all medical eligible students in California became eligible for both physical and behavioral health services based on the approval of the federal government.

Eligible services were also expanded, as was the list of individuals who are eligible to deliver those services in California. That means that more than 60% of all of our public school students are medical eligible. And more than half of them would be eligible for these vital services. While only half of the LEAs participate in the BOP program. Even though most LEAs are delivering services but are not seeking the federal reimbursement due to the burdensome and punitive nature of the DHCS audit process for Leabop.

When we talk about funding for schools, the amount of money LEAs are eligible to receive in reimbursement for services, but do not currently Bill for is foundational to students receiving a wide variety of health services at schools that directly impacts their efforts to maximize their educational opportunities for success.

Since 2021, the Department of Healthcare Services, because of SB 75, the 2019 budget Trailer Bill, has had a roadmap as to the improvements needed for the DHCS audit process, including a greater focus on providing support and technical assistance to LEAs. Increasing the participation of LEAs in the BOP program, along with billing for more eligible services, will result in increased funding available to support student services.

As a sidebar, one of the efforts included in the $4 billion Children and Youth Behavioral Health Initiative is a new fee schedule for LEAs and managed care plans providing reimbursement for behavioral health services only. One can only imagine, if we can't maximize the opportunities for LEAs to readily and easily participate in the existing LEA BOP Program, how an additional billing system will fare.

We want to thank Assembly Member Wood and Assembly Member Muratsuchi for carrying on this valiant effort, and we can only hope that sometime in our lifetime we have fixed this problem. Appreciate an aye vote. Thank you.

Thank you very much. Next person in support, please.

Good afternoon, chair and Members. I'm Derek Lennox. On behalf of the 58 California California County Superintendents of Schools with the California County Superintendents Association, pleased to co sponsor this important measure and grateful to Dr. Wood and Assembly Member Muratsuchi. California is currently in the midst of reshaping what our public schools look like. We're bringing more services to campuses where the students are, we're bringing more providers to the students. We're bringing that funding to where the students are.

And this is all part of a critical transformation that's currently happening. It's nearly impossible to do that without ongoing resources in California, the only ongoing funding currently available to support this work is the Lea BOP program, which, as you've heard from the presenting Member and speaker so far, has a history of systemic issues associated with it. This is a problem because California has an ongoing youth mental health crisis along with the rest of the nation.

In a 2022 statewide survey commissioned by the California Endowment, 75% of youth reported anxiety, more than half reported depression, 31% experienced suicidal ideation, and 18% of youth indicated that they have self harmed. The crisis is currently surging. And it's a problem this Bill is going to help address because were we to draw down more of the medical reimbursement rates similar to inconsistent with large states like California, it would increase federal funding for student health and mental health services by approximately $1.3 billion annually.

This is money that would ensure that special education programs are adequately funded and that school based health centers, behavioral health services, and wellness programs have ongoing financial support. For these reasons, I respectfully ask for your support for AB Four and would be happy to answer questions at the appropriate time. Thank you very much.

Thank you very much. As a speaking in support just now, name an affiliation, please.

Good afternoon. Amanda Dickey on behalf of Santa Clara County Superintendent of Schools, in support.

Thank you.

Good afternoon. Chair and Members Serette Kaminski on behalf of the Association of California School Administrators also on behalf of the Association of School Business Officials in support thank you.

Thank you very much. Next person.

Good afternoon. Brian Ricks with the Los Angeles Unified School District in support.

Thank you.

Good afternoon. Marcel Reynolds with California School-Based Health Alliance in strong support.

Good afternoon. Jessica Hay with the California School Employees Association in support.

Thank you very much. Okay, anybody speaking in opposition to this Bill? Seeing none, we'll go to the phone lines, moderators, or anyone in the queue on this Bill.

To testify in support or opposition, please press 1 0. And first we'll hear from line 227. Please go ahead.

Sam Nasher with the Los Angeles County Office of Education support.

Thank you very much. Next person, please.

We have two more people queuing up. It'll just be one moment, please. Will we provide them with line numbers. And next we'll hear from line 218. Please go ahead.

Good afternoon. Megan Chung with the Steinberg Institute in support.

Thank you.

And line 230.

Madam Chair, Members, Laura Wasco on behalf of the California Association of School Psychologists in support of AB 483.

Thank you.

Madam Chair, there are no further comments.

Thank you very much. Bringing it back to the committee. Comments, questions? The Bill has been moved. Would you like to close, sir?

Just respectfully ask for your aye vote. Thank you.

Okay, we will take that up when the time comes. You want to move on to 1331?

Yes. Thank you very, thank you very much.

Let me see. Let's go ahead and do the roll call on that.

Okay.

Do pass as amended and referred to the Committee on Appropriations. Secretary?

Senator Eggman aye. Nguyen. Glazer. Gonzalez aye. Grove. Hurtado. Limon. Menjivar. Roth. Rubio. Wahab. Wiener.

Okay, we'll hold that open. Now we'll go on to 1331, sir.

Thank you, Madam Chair. And senators. California has a fragmented and decentralized health information exchange network with limited participation by major types of healthcare providers. This limits the ability of patients, healthcare providers, and public health departments to use data to improve healthcare quality and care coordination.

In 2021, the California Health and Human Services Agency created a data sharing agreement defining the parties subject to new data exchange rules, setting forth a common set of terms, conditions and obligations to support secure, real time access to an exchange of health and social services information and in compliance with applicable federal, state, and local laws, regulations and policies. This Bill establishes the next step by creating a data exchange board to develop recommendations and any changes to the framework.

Recent amendments include the addition of an enforcement framework, best practices to collect individual level demographic and health related social needs data, and a description of qualified health information organizations. I want to thank the committee and your staff for your work on this Bill. I'll be accepting the amendments described in the analysis, and I respectfully ask for an aye vote.

Okay, thank you very much. People speaking in support of this Bill. Today first lead witness.

Yes, hi. Chair and committee Members. Kiran Savage-Sangwan. On behalf of the California Pan Ethnic Health Network, we support this Bill. We want to thank the author, the author staff, the committee, and also the Administration for working with us to address our concerns on the original Bill and to bring us to a strong support position.

As the author mentioned, our healthcare system is highly fragmented, which presents challenges for all of us as consumers. Our data is siloed and often not available to address either our individual health concerns or to help us advance population health as a state. When health data is held independently and not shared, it is very difficult to provide the high quality, linguistically and culturally responsive and personcentered care that we strive for in this state.

Currently, all of us as consumers bear the burden of taking our information from one provider to the other, whether that's our health history, our prescriptions, our allergies, our medical conditions, et cetera. And we believe that consumer health data should be available to improve the health of consumers and communities first and foremost, which is why we support the data exchange framework that was established by the Legislature in 2021. This Bill does a couple of really important things.

One is to ensure strong and transparent governance through a neutral governing body that includes consumer representation, has appropriate conflict of interest provisions, has clear roles and authority, and provides an annual report to the Legislature. The second thing is to further the health equity goals of the data exchange framework by taking steps towards using best practices to require the collection of individual level demographic and social needs data.

And the third is to promote the success of this framework that the Legislature adopted by adding mechanisms for the state to enforce the requirements of the law and the data sharing agreement. Unfortunately, although many entities are currently required to be signatories to this framework, many are viewing this as optional and have not signed. And it's therefore important that the state provide a mechanism to enforce not only signing the agreement, but also the policies and procedures that come along with it. It's important for consumers to know that their information is safe and secure and will be used in their best interests. So for this reason, we support the Bill and thank the author and thank the Chair and urge your support.

Thank you very much. Next person, please.

Hi, thank you. My name is Lori Hack, and I serve as the interim Executive Director for the California Association of Health Information Exchange Organizations. We're called CA-HIE. We have been a coalition of organizations, including health systems, not for profit, community based organizations, technology leaders, and even individuals who've worked for the past 15 years in California to facilitate health information exchange. This is enabling our stakeholders hospitals, clinics, medical groups, behavioral health providers, county health services to share data about Californians. As a Member of Khigh, we are serving as the backbone of the state's health information exchange infrastructure and we strongly support AB 1331.

And really thank you for providing this opportunity to codify and amend the law to add things that we support, such as the qualified health information exchange requirements enforcement. As we just heard, we also support as well. We are already in support of the governance as it's been amended, and we particularly applaud this requirement for the qualified HIOs to be not only nonprofit organizations, but that they are networks that welcome the participation of any hospital, healthcare provider, health plan or public health organization in their service area.

For the past 15 years, our HIO Members have partnered with national and state level technology vendors so that we can help create this background infrastructure in California. But most importantly, we have, as nonprofit organizations, partnered with the stakeholders in our local communities. We are providing affordable services to safety net providers that are making up so much of the healthcare delivery in our state.

The designation to offer a nonprofit qualified Hio option to safety net providers and organizations around the state as an alternative to the technology vendor offering that already exists, ensures that there will be inclusive access and a process for providing crucial healthcare data, regardless of the resource geography or payer for this diverse population in California. The nonprofit status also allows the organizations to reinvest in their communities to further advance health information exchange for the many areas in which it needs to be provided.

One final comment on our support of the qualified hio requirements in this Bill is the requirement about the explicit data requirements. I know it seems excessive, but these minimal requirements that are listed in the Bill are necessary to help level set. So we assure that the participants are sharing the types of information that's needed to make clinical decisions.

And finally, this particular area of health information exchange as a nonprofit status is really a mirror of state regulation already enacted in states such as Arizona, Delaware, New York, Wisconsin, Vermont and several others. Some of these states have even used this as the exclusive mechanism for data sharing. And you'll need to wrap up. Okay? So before I conclude, I want to say we agree with the enforcement provisions. We are thrilled to have this Bill in place and we find it as just a next step in our process for data sharing.

Others now speaking in General support name and affiliation and if we could keep that aisle open, there's a lot of space in the room for people lining up.

Thank you, Jennifer Robles with Health Access California and support.

Thank you. Sandra Poole. Western Center on Law and Poverty and Support.

Thank you, Lauren Nolan Hajik. On behalf of Blue Shield of California in support. Thank you.

George Soares, California Medical Association support, if amended, appreciate the recent direction of the amendments and we'll continue working with the author and committee. Thank you.

Thank you, Madam Chair and Members. Teresa Stark with Kaiser Permanente. If I could take a minute. We are in a supportive amended position. We do agree with the author on the goal to improve health information exchange in California and get that data exchange framework up and running. We do have a few suggestions that we think would strengthen the governing board itself, which we're happy to continue to talk to the author.

Again, our main concern with the Bill is that definition of qualified health information organization that does stray from the work that actually Dr. Wood referred to the work at the data exchange framework. Almost two years of work has gone into actually deciding what a Qhio is, what the definition is, hours of meetings. It has gone a different direction from what's in the Bill. And so I think we want to just be careful that we do respect that process at the agency over at CDI.

That is the direction that health information exchange is going in this country. This actually is not what's in the Bill. So I think we want to just be careful about how we define a Q, Ohio and not have it be the central repository of health information because there are some risks with that as well and it's not necessary. So happy to talk to the author's office and continue to work with his staff on this. But with the removal of that, we'd be happy to support the Bill. Thank you.

Okay. Anybody in between? I see hesitancy there.

In between in the opposed and less amended category. Good afternoon, Madam Chair and Members. Connie Delgado, on behalf of Point Click Care, here respectfully oppose, unless amended to AB 1331. Members Point Click Care is a leading healthcare technology platform enabling meaningful care collaboration on patients healthcare journey dedicated towards increasing and improving inoperability.

Point Click Care is partnered in over 50% of California hospitals and 900 skilled nursing facilities, and fully supportive of statewide data infrastructure in California. And patients and providers would like to ensure that we don't create barriers or hinder the long term success of data exchange framework.

As we begin the process of this important work, we are particularly concerned with explicitly preventing participation for for profit entities to participate as a Qhio in these public private partnerships, which we believe could stifle innovation in cutting edge technology developments and protection of patient sensitive data. We are trying to understand the affiliation language of the Bill, which we feel prevents organizations affiliated with healthcare organizations or EHR vendors from becoming a Qhio and might increase costs for providers.

Lastly, we believe existing relationships between providers, their communities, technology partners should be preserved as long as they are able to meet the technical requirements put forth by the state and are concerned that this could lead to siloed data repositories. Thank you. For these reasons, we've respectfully asked for your no vote, and we hope to continue conversations

So that sound like opposition then.

That's opposing less amended.

I'm sorry, are you in opposition or where are you?

In between. Thank you, Madam Chair, for your flexibility. Mark Farouk, California Hospital Association. Also speaking for the Association of Public Hospitals, we provided a letter of concern to the committee and to the author's office. I also want to thank the author for the time we've spent with his staff talking about these issues.

We remain concerned regarding the recent amendments to the Bill that would impose significant penalties on hospitals for not signing under the agreement that is not yet finalized and lacks clarity on several critical points. Hospitals have every intention of complying, and we want the Health Information Exchange to work, but it is critical that everyone subject to the agreement have a clear understanding of how to be in compliance.

The DSA remains unclear related to several fundamental components, as it references multiple policies and procedures that have yet to be developed, meaning that what compliance may look like is still uncertain. It's critical that we get this right. We look forward to continuing to work with the author staff and the Committee. Thank you.

Thank you very much. Others speaking in opposition generally sort of lee. Okay, let's go to the phone lines. Those speaking in opposition and or support and or in between, just name an affiliation.

To testify in support or opposition to AB 1331, please press 10. We do have a couple lines queuing up. It'll just be a moment, please, while we provide them with their line numbers. One more moment, please. And now we will hear from line at 233. Please go ahead. Your mic is open.

Hello, Olivia Bunchu. On behalf of Connecting for Better Health, we strongly support this Bill. Thank you.

Next caller, please, in line 217.

California. And I am in opposition to this Bill.

Madam Chair. There are no further comments.

Okay, thank you very much. Bringing it back to the committee now. And just to confirm, the amendments you're taking are to add privacy, confidentiality and security to the topics to be developed under the policies and procedure. Require CDI to report violations to any other entities authorized to ensure compliance with data sharing policies and procedures. Make the board subject to Article three. Require the board to review, modify, and approve new data sharing requirements.

Authorize the board to call emergency meeting for the purpose of federal regulatory compliance with at least five business days notice and to ensure that at least one board meeting occurs before adoption and clarify what Qhio criteria is correct. Okay, bringing it back. Very complicated stuff you're working on. And I know you've been doing this for years now, and so anytime you do that, I think there's going to be a lot of opinions here, there, and everywhere. So we appreciate this work.

I think this is vitally important that we can get all kinds of things online. Our health records should be able to follow us wherever we go, no matter what the system we're in for complete and accurate care. So I'm a big supporter. Would you like to close?

Well, thank you very much, Senator. And it is complicated, but the premise is pretty simple. And let me just illustrate that because I think it's important. Years ago, I was a patient at an emergency room at a UC hospital in San Diego. Unfortunately, I don't have a lot of health issues, but had I, there was no way that the UCS could really communicate in real time with my health provider, Sutter Health.

And that was actually one of the things that started me thinking about the need for this kind of data. People seem to forget or not want to talk about the fact that your health data is not the property of your healthcare provider, it's the property of the patient. So whoever your provider is, is a custodian of that record. And so it's important to me that we get everybody in on this. And I want to appreciate that.

The folks that have signed the agreement and there will be opportunities to work through the process, and then there will be an opportunity to ratify this at the very end of the process there. But there are some players that have not, and one of those is the UC hospitals have not signed on. And I'm very disappointed in that because my health provider Kaiser Health has, Kaiser has, others have. But the UCS have not signed on. And I'm really, really disappointed in that.

I hope that they actually do. They are affiliated with us here. They do get funding through the state, and I'm disappointed that they're not. And I really haven't received any sort of great answer for that. So the goal is that we have real time information exchange in the interest of making sure that patients get the appropriate care at the right time.

And had I been ill, had some major condition, the UC hospitals would not have been able to necessarily communicate well, and I might have gotten inappropriate care. I might have had an MRI a week before and had another MRI there. These are the kinds of things that lead to increasing costs and inefficiencies in the system, and we need to change that redundancy. So that in a nutshell, I probably made it more complicated by trying to make it less complicated. But it is about real time information exchange so people can get appropriate care, and also the ability to collect information for research and data and looking at specific communities and disparities in healthcare and trying to use that data to help improve health care for those folks.

Thank you.

So I respectfully ask for your vote.

All right, get a motion. So moved by Senator Roth, and it is do pass as amended and re-referred to the Committee on Appropriations. Thank you,

Senator. Egman aye. Eggman. Aye. Nguyen Glazer. Gonzalez. Gonzalez. aye Grove Hurtado. Limon Menjivar. Roth. Roth. Aye Rubio Wahab Wiener.

Just a healthy three, but you got there okay. Move on to AB 1537.

Thank you very much. And this is the last one today, Members. I think I have one on consent. Unless it got pulled off.

No, you're fine.

Thank you. So thank you very much, Madam Chair and Members. This is AB 1537. This bill makes important changes in how skilled nursing facilities will manage their money. It will improve the quality of care that residents receive. The bill requires a facility to spend 85 percent of its total revenues on direct patient care, much the same way that insurance companies are already required to spend 85 percent of revenues on patient care through the use of the medical loss ratio, or MLR.

Direct patient care includes, and appropriately so, staffing, wages, benefits, therapy, supplies, pharmacy, plant operations and maintenance, laundry, dietary, all the things that directly benefit a resident of a nursing home. Non-direct care that won't count towards the 85 percent spending requirement, that includes administrative costs, executive wages, payments to management companies, home office expenses for parent companies, and profits paid to contractors or related party entities, among other things.

Related party entities, a subject I've spent much time to understand, are companies affiliated with the skilled nursing facility ownership that they use to increase profits, often paying themselves much more than the costs allowed by Medi-Cal or Medicare. For example, facility owners right now are taking advantage of loopholes that allow companies to own, say, five facilities and to use a related entity they also own to bill thousands of dollars every month in administrative fees or using a laundry company they also own to bill each of their own facilities what may be over-market fees for service.

I'm in conversations with the Administration regarding technical amendments to streamline the implementation, which will include a delayed implementation timeline to allow skilled nursing facilities to adjust to these changes. There is no opposition to this bill that I hope-- we'll find out--but I respectfully ask for an aye vote.

Thank you very much. Apparently, we recently received a letter of concern. We'll see. Okay, people speaking in support, now would be the time to come forward. We have lead witnesses today, Assembly Member? Okay. Just general support? Okay, seeing none. I have a long list here, though. Opposition? Are you with your letter?

Yes, I am.

I'm a bit of a tweener, I apologize. Jennifer Snyder with Capital Advocacy on behalf of the California Association of Health Facilities. The Assembly Member knows we submitted a letter of a concern, mainly based on what we understand will be technical assistant amendments from the Department of Healthcare Services. We have a neutral position on 1537.

Okay.

We went to a neutral position on a previous bill that it is identical to AB 2079, and we're incredibly grateful in working with the author on that bill and continue to be in that neutral position. I think the concern is that as the Department provides maybe technical assistant amendments a little late in the process, we wanted to make sure that we talked about a couple of considerations that the association wants the Legislature to understand and consider based on what we possibly think the Department is going to come out with their Department amendments.

First and foremost, part of what we negotiated with the author back in 2022 was to assure that the bill only dealt with those funds that the state regulated, meaning that the bill deals not only with revenues, but costs, but also oversight with the Medi-Cal program, and so the way that 1537 is constructed right now, it only applies to Medi-Cal funds, both costs, revenue, and regulatory oversight. It does not deal with Medicare funds.

And we believe that Medicare, again, is under the oversight of the federal government. They regulate how those funds are utilized, and they provide the oversight for those funds, and so part of what we negotiated with the author was relative to making sure that we keep Medicaid and habit only Medicaid. The second is what's important for providing quality patient care is to make sure that the facility is also a quality facility.

So anything relative to capital costs, rent, lease, the beds that our patients sleep in, the equipment that they use, it's important that appropriate costs relative to that are factored in. And so we hope in the Department's amendments, both relative to what monies are looked at and what costs relative to capital costs are included, we want to make sure that the spirit of that is still included as 1537 moves forward. Again, really appreciate all the work we've done with the author.

I am very hopeful that we'll continue that way, and so at this point, just concerns, no opposition. I appreciate the Committee's indulgence. Thank you.

Alright. We hope the Department is listening. Okay, any questions, comments? Oh, let's go to the phone lines. We have somebody else? Oh, please, go ahead.

Madam Chair. Good afternoon, Madam Chair and Members. Norland Asbrick on behalf of Providence. Providence is one of the--well now one of the largest skilled nursing facility operators in California. I just wanted to share that we share the concerns that CAHF has raised to AB 1537. We specifically have concerns around the definition in the bill related to direct patient related services.

If applied, this would actually have a direct negative impact to our facility's ability to provide high quality care, especially to Medicare patients. So thank you.

Thank you very much. Okay. Now going to the phone lines. Moderator, is there anybody on the line?

Ladies and gentlemen, if you wish to speak in support or opposition, please press one, then zero at this time. There's currently no one queuing up at this time, Madam Chair.

Okay, thank you. Bringing it back to the Committee. Questions, comments, motions?Motion. Senator Roth will move the bill. Would you like to close?

Thank you. Thank you, Members, and thank you, Madam Chair. I guess I was listening to the concern. My hope is that Medicare patients and others that--we're not going to create two standards here. I would hope that there would be--abiding by the spirit of what we're asking for with our Medi-Cal population, remind me, these are all vulnerable people.

So I'm hopeful that we're not looking at facilities, looking at the opportunity to say, 'well, we'll do that for Medi-Cal, but we're still going to do all these other things related to private pay or Medicare.' That would be a problem. And trust me, if that were to happen, we'd probably be pushing on ways to fix that. So I hope that in spirit, that this is the benchmark and that going forward, that's how it's played out. So I respectfully ask for your aye vote.

Okay, thank you very much. Secretary, if you could please call the roll, and the motion is do pass and refer to the Committee on Appropriations.

Senator Eggman?

Aye.

Eggman, aye. Nguyen? Glazer? Gonzalez? Aye. Gonzalez, aye. Grove? Hurtado? Limon? Menjivar? Aye. Menjivar, aye. Roth? Aye. Roth, aye. Rubio? Wahab? Wiener?

Four? We'll hold the roll open. Thank you very much, Assembly Member. Assembly Member Zbur waiting patiently here.

Thank you, Madam Chair. Committee Members.

Let me start by extending my thanks to you and the committee staff for your incredibly nice engagement on this Bill. We will be accepting the amendments in response to the comment and the analysis related to the implementation date. Today I'm proud to present AB 1645, which is sponsored by Insurance Commissioner Ricardo Lata, Equality California, APLA Health, the Los Angeles LGBT Center, and the San Francisco AIDS Foundation.

A couple months ago, you may have seen headlines about a federal judge in Texas who struck down national protections for preventive care benefits under the Affordable Care Act. While we do have protections in California, some of them are based on the federal protections. So there is a concern that this Texas case may put the federal preventive services requirements on which our state relies into peril.

Among other things, AB 1645 will codify in California law existing federal guidance to ensure that consumers can still access preventive care and all the necessary services for delivering that care without cost sharing should federal law ultimately be struck down on appeal. So this Bill is about protecting Californians from the sweeping health care rollbacks we're seeing coming out of conservative courts in Texas and elsewhere. Every Californian deserves access to preventive health care that is comprehensive, inclusive, and affordable.

Californians most affected by STIs include people of color, young people ages 15 to 29, LGBTQ plus people and people who use substances. Underlying these disparities is a lack of primary and preventive health care due to a range of factors, including family rejection, unemployment, homelessness, or lack of culturally competent local services or providers. Comprehensive, inclusive, and affordable preventive care is critical to identifying and addressing health challenges before they become serious, particularly for marginalized populations.

Our sponsors have dedicated themselves for years to strengthening access to Prep, a life saving HIV prevention medication, because they understand that comprehensive coverage for preventive health care is critical to maximizing utilization and preventing HIV. The same can be said for other preventive care that falls under the Bill. Barriers to preventive care force people to choose between preventing expensive and devastating health problems before they occur and putting food on the table.

In essence, this Bill is about ensuring that low income people have access to the same comprehensive and affordable preventive health care as anyone else. I ask for your aye vote at the appropriate time. Today with me, I have Josephine Figueroa, Chief Deputy Legislative Director for the Department of Insurance, and Alice Kessler, on behalf of Equality California co-sponsoring of the Bill.

Good afternoon, Madam Chair, Members of the committee. Josephine Figueroa, Chief Deputy Legislative Director for the Department of Insurance, under the leadership of Insurance Commissioner Ricardo Lara. I first want to thank Assembly Members Berg for authoring this important measure. Insurance Commissioner Lara is a proud co sponsor of AB 1645, which would remove barriers to accessing 0 dollar preventative care under the Affordable Care Act and add CDC recommended screening for sexually transmitted infections to the list of preventative care benefits.

Thank you very much. First person, please.

STIs have been growing over the last 20 years and impact California's community disproportionately obviously already stated including communities of color, youth and the LGBTQ plus community. Underlying these disparities a lack of primary and preventative health care due to a range of factors, not the least of which is a lack of access to culturally competent local services and providers. It's important to remove cost sharing from preventative care services because cost sharing has been found to worsen disparities in access to health care and adversely affect health.

By requiring STI screening. It is recommended by the CDC to be covered without cost sharing. AB 1645 will also improve health outcomes by detecting STIs before transmitting it to others, treating them before they develop and it into more serious conditions. This measure will make it possible for preventative care to be delivered and more STIs be detected earlier, resulting in improved health outcomes. AB 1645 also codifies existing federal guidelines providing that integral health services must be covered without cost sharing.

Thank you very much. Next person, please.

Thank you. Madam Chair and Members. Alice Kessler I'm here on behalf of Equality California.

Codifying integral services requirement in state law is particularly urgent in the wake of the Brayward Bee Bessetter decision striking down preventative requirements. We must ensure that California will continue to provide access to preventative care for all as potential continued changes by some federal courts may attempt to curtail access to these essential services. On behalf of Insurance Commissioner Ricardo Lara, I ask for your aye vote.

We're a proud co-sponsor of AB 1645 and the attacks on the ACA are real. We know that is happening. Many of us who co sponsoring this Bill have been working on improving access to preventive care, such as prep pre exposure prophylaxis, for many years and these attacks are indeed very much undermining the promise of those protections and that access for Californians.

We're grateful to Assembly Members Zabur and Commissioner Lara for their leadership on the Bill and strengthening these preventive care mandates in the face of these attacks, not to repeat other testimony that's been given. But essentially we need to improve access to culturally competent STI services by requiring health plans to reimburse nonparticipating essential community providers such as Federally Qualified health Centers and other community clinics for STI screening.

AB 1645 is a common sense Bill to increase the availability of STI screening for many of our vulnerable populations in California and we urge the committee to pass the Bill. Thank you. Thank you very much.

The speaking in General support. Name and affiliation, please.

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

Thank you.

Madam Chair Members Darby Kernan, on behalf of 2 of the co sponsors San Francisco AIDS Foundation and APLA Health, as well as for Essential Access Health. Thank you.

Thank you very much.

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

Thank you.

Madam Chair Members, Rand Martin on behalf of the AIDS Healthcare Foundation in support. Thank you.

Thank you very much. Okay, let's go to anybody speaking in opposition to this Bill today.

Jennifer Robles with Health Access California in support.

Good afternoon, Chair and Members of the committee. Robert Boykin with California Association of Health Plans. Regrettably, in opposition to AB 1645. We respect and understand the intent of the Bill. However, we are opposed because this removes cost sharing on services that are 99% covered by health plans. According to the California health benefits review program, this will increase annual costs by 20 million for all Californians. The tradeoffs are real. Reduced cost sharing for one benefit will result in higher cost sharing for other benefits.

This is 1 of 21 mandate bills this year that when taken altogether, are set to increase annual costs by more than 1 billion on all Californians. For these reasons, we are opposed to AB 1645.

Thank you very much. Anybody else speaking in opposition today? Second person.

Thank you. Preston Young from the California chamber of commerce here today in respectful opposition to AB 1645. Just briefly, I don't want to be redundant. The policy is not what we take issue with with the Bill. We are concerned about the unintended consequences, the costs that are associated with these mandates. I realize when you look at one, it doesn't look bad. But when you put them all together, as the plans just said, the cost does increase quite a bit.

The average annual premium for employer sponsored family health care coverage reached over $22,000 last year. So this is what I hope we remain cognizant of when we discuss mandates. Thank you very much for your time and your consideration.

Thank you. Now others just name and position.

John Winger on behalf of America's Health Insurance plans would also echo the comments of the chamber and cap.

Thank you.

Matt Aiken on behalf of the association of California Life and Health Insurance companies in opposition.

Thank you very much. Okay, let's go to our phone lines now. Anybody speaking in support and or opposition, now is the time.

Ladies and gentlemen, if you wish to speak in support or opposition, please press one and zero at this time. We'll be going to line 237. Please go ahead.

Good afternoon. Molly Robson, Planned Parenthood, Affiliates of California in support. Thank you.

And we did just have a few others queue up during that one moment while they were given their line number.

Next we'll go to line 238. Please go ahead.

Hi. Philip Champagne, APLA Health, strong support. Thank you.

Thank you.

Next we go to line 239. Please go ahead.

Andi Liebenbaum on behalf of the County of Los Angeles, in support.

Thank you.