Senate Standing Committee on Health

People and supporters and opposition can get right up here with us. So, welcome to 2024. Senator Umberg, would you like to begin?

Thank you. SB 26. SB 26 builds on the work and the leadership of the chair concerning care courts. Although it's broader than just care court, one of the great challenges we have in terms of making sure that those that are in need of professional behavioral health care have the ability to receive it, and that we have the capacity to provide it. And one of the key challenges in terms of capacity is just the number of qualified healthcare, behavioral healthcare professionals.

What this Bill does is this Bill provides a scholarship for those who wish to become behavioral healthcare professionals, and it's in exchange for their agreement to be able to continue to work in the field for a period of time. I recognize that we are short some money here in the state, and as this Bill progresses, that we will have to find ways to fund this Bill. But I think it's incredibly important.

So much of what we do in mental health, as the chair knows, is dependent upon our capacity to provide those services. And so with that, I would ask for an aye vote I have no witnesses. I'm the witness.

Okay, well, that makes it easy. We like that. And the Senator underplays his engagement in the care court, as well as the primary author. Okay. At this point, would any Members like to have any questions, comments about the care court scholarship program? And, of course, this is all going to be, of course, dependent upon appropriation and the Department setting up some parameters and everything for this.

May I make the comment?

Yes.

Well, first of all, I just want. To thank you for that, because I think it's important to have this program. And hopefully we could get funding, but I'd like to be added as a co-author, since I'm a co-author to your other Bill. Thank you.

Thank you. We welcome it. Thank you, Senator Rubio.

Okay. Seeing no other Members, Senator Wahab, I'll move when appropriate. Okay. Thank you very much. We don't have a quorum at this time, but would you like to close, sir?

I would urge an aye vote.

All right, thank you very much. We will take that up as soon as we get a quorum. Again, I would encourage Members to come down. What's that? zero, do you want any opposition? Thanks, Tom. Any opposition? All right. No? Okay. But thank you. All right. Takes a village. Okay.

Urgen an aye vote. Thank you very much. All right.

Thank you. I want to say you're dismissed, but. All right. Moving on to file item number three, SB 294, Senator Wiener having to do with healthcare coverage and the independent medical review. Thank you to our friends for being here. Upstairs.

And again, if I could ask other Senators to come so we can establish a quorum. Thank you very much. Whenever you're ready, Senator.

Okay. Thank you very much, Madam Chair and colleagues. I'm here today to present SB 294, which is similar to a Bill that passed out of this Committee last year, which was SB 238, whose goal is to expand access to mental health treatment for young people.

Specifically, the Bill provides that if a health plan denies or delays, obstructs coverage for behavioral health treatment for someone under the age of 26, there will be an automatic independent medical review instead of the normal process where you have to go through an administrative process and then seek an IMR. We know that when IMRs do happen for this category of youth seeking behavioral health treatment, overwhelmingly they win their IMR. So we know they're entitled to this coverage.

We also know that there are a lot of families that do not even know that they can seek an independent medical review, and they are disproportionately lower income families where English is not the first language and so forth. So this is an equity issue as well. And so we think that this Bill will ensure that people can actually access their health insurance when their children are either not yet in crisis.

Hopefully, all too often in our system, we provide mental health treatment when people are already in crisis. We want to help people before they are in crisis, and we know that our young people are really struggling right now with mental health challenges. So I respectfully ask for your aye vote. And with me today to testify is Adrienne Shilton, Vice President of Public Policy and Strategy with the California Alliance of Children and Family Services, and Nora Lynn with Children Now.

Thank you. Ms. Shilton, would you like to go first, or who's going first?

Madam Chair and Members, my name is Nora Lynn, and I'm here on behalf of Children Now, a state based research and advocacy nonprofit organization focused on children's health, education and welfare. We're the sponsors of SB 294. As the Committee's analysis lays out through its Department of Managed health care and Department of Insurance, the state regulates health plans and disability insurers. They issue guidance for plans to use in providing medically necessary mental health and substance abuse disorder care.

They have grievance systems to which care denials can be appealed, and they are required to expeditiously review cases submitted for independent medical review and immediately notify enrollees of their decision. IMR statistics paint a clear picture that health plans are failing to ensure mental health services for young people, and the state has yet to implement a new system to address this issue.

We know, based on the DMHC data that Senator Wiener referenced, that between 2017 and 2022, most mental health denials for youth were later overturned by the IMR. The increasing numbers of youth failing to get the mental health treatment they're prescribed in a timely manner speaks to the need for reform. While more youth are accessing the independent medical review process, care continues to be denied at an alarming rate.

The state has a role to play when prescribed mental health care is denied, and SB 294 will ensure state oversight of health plans by requiring health plans to automatically submit any denials of mental health care for youth up to age 26 to their grievance process. If a plan continues to deny care following the grievance, the case would be automatically submitted to the IMR for denials in life-threatening and serious cases, the appeal to IMR would be direct.

California's mental health crisis has become a full blown emergency and the system we have in place to provide mental health care for our youth is broken. Plans too often fail to provide the mental health care needed, and when that happens to children, the results are disastrous. For these reasons, we request your aye vote on SB 294.

Thank you very much.

Good afternoon, Chair Eggman and honorable Members of the Senate Health Committee. My name is Adrienne Shilton. I'm with the California Alliance of Child and Family Services, and we represent 167 nonprofit, community-based providers across California serving vulnerable children, youth, and families in our safety net. We are a proud supporter of SB two and vantage point representing these nonprofit organizations working with the children, youth and families with mental health needs. We see an urgent need for this Bill.

Our members report to us almost daily the families that have been denied coverage by their insurance company, and this is devastating as symptoms can worsen for their children. So when youth get appropriate level of care, the appropriate amount of time, their symptoms get dramatically better. That's been our experience. So I wanted to share one story from one of our Member agencies to make this point, we changed these name and details to protect his privacy.

Matthew is a 14 year old boy who came to one of our Member agency's residential programs last year. He has three back to back hospitalizations and an attempted suicide. Before he was adopted by a relative at the age of five, he had been terribly abused by his biological parents. He suffered PTSD, and he was on five different medications. So after three weeks in our Member agency's program, however, Matthew's insurance company denied any additional days, stating that he no longer met medical necessity.

This was despite his psychiatrist recommending further treatment. So hoping the appeal process with her insurance company would change the result, Matthew's mom took out a loan while she awaited the outcome. However, after two weeks, the mother had exhausted her financial resources, and without other options, she took Matthew home. So after waiting another week, Matthew's mother learned that the appeal was unsuccessful, and only then could Matthew's mom file a complaint with Department of managed healthcare.

So, meanwhile, during this time, he had been re hospitalized in another attempt of self harm. This is all so unnecessary. We are in the middle of a devastating behavioral health crisis among our youth, as all of you know. And stories like this are unfortunately not uncommon in the mental health field. So our members are frequently seeing parents faced with this awful choice after denial, which is to end treatment and take the risk of their child's condition worsening or take on financial hardship to continue the treatment.

So placing the entire responsibility on the family to initiate the IMR, from our perspective, is just a recipe for failure. And so, really, in all but the most rare exceptions, at least with the clients that we are serving, families in crisis that just do not have the resources. So we believe that SB 294 represents one solution that will have a direct and positive impact on children like Matthew. So we urge your support today. Thank you.

Thank you very much. Anybody else speaking in support of this measure today? Just name an affiliation now.

Linda Way with Western Center on Law and Poverty in support. Thank you.

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

Thank you.

Andrea Rivera, on behalf of the California Panethnic Health Network, in support.

Thank you.

John Drebinger with the Steinberg Institute in support and also here in support on. Behalf of the Kennedy Forum. Thank you.

Awet Kidane with the California Children's Hospital Association in support.

Thank you. Josh Tosney with Santa Clara County in support. Thank you.

Good afternoon, Chairman Members. Bryant Miramontes with AFSCME in support.

Thank you very much. Okay, seeing nobody else speaking in support, we'll take opposition now.

Madam Chair Members. Stephanie Watkins, on behalf of the Association of California Life and Health Insurance Companies here in opposition to SB 294 today. First and foremost, I'd like to thank the author, the sponsor and staff. We have been working closely with them over the last year to try to find some pathway forward to address this important issue. Unfortunately, we are in opposition today.

It goes without saying that mental health is a key component to a person's overall well being, and health plans and insurers remain steadfast in our effort to provide self safe, evidencebased behavioral health care in accordance with existing state and federal requirements. While we appreciate the overarching goal of ensuring enrollees insured have access to important medically necessary mental health services, we believe that this Bill is missing key considerations in the determination process that would interfere with the patient's ability to get that care they need.

Specifically, we're concerned that this Bill will substantially alter a health plan insurer's internal review structure by creating a new bifurcated process for the purpose of reviewing youth mental health services. As drafted, the Bill creates a unique two tiered review system, which requires the health plan and insurer to automatically review all health related medical health services when the plans have issued initial denial or modification. It also requires plans and insurers to sidestep the plan and insurer's internal process and automatically submit specified cases to the IMR process.

While many initial denials and modifications can be resolved through a plan or insurer's internal review process, it would be of an overstatement to suggest that every modification or denial should automatically be submitted. The success of these cases and the reviews are largely dependent on the engagement of the individual patient and or physician. Without their involvement, the secondary review process will likely result in an increase of unnecessary adverse benefit determinations, which will have the negative effect of further delaying care.

Additionally, while the sponsors have attempted to address the privacy concerns we have raised, we remain troubled that the process outlined puts both plans and insurers and the state's IMR process in an untenable situation. The Bill requires us, upon issuing a modification or denial of service, to immediately submit the grievance along with all relevant information to the state's IMR system.

Yet, without a patient's informed consent, the plan insurer lacks the authority to release critical patient information necessary for the review to make a judgment as to the appropriateness of care. While the Bill requires a plan insurer to coordinate with the Enrollian provider for the completion of assigned IMR application that could take days or weeks. With that in mind, while we share the Bill, sponsors view that children with mental health and substance use disorders should receive the medically necessary care that they need.

We believe that SB 294, as drafted, may have numerous unintended consequences and could actually delay care while simultaneously building in more unnecessary cost to the system. For those reasons, we remain opposed. Thank you.

Good afternoon, Madam Chair, Members of the Committee. Jed Hampton with the California Association of Health Plans, representing 44 licensed plans, representing 27 million Californians across the state. In the interest of time, I will associate and echo much of my comments to my colleague from the Association of California Life and Health Insurance Companies. I do again want to thank the author and staff and sponsors for working with us.

As my colleague had mentioned, we have done quite a bit of work and had quite a few conversations around this Bill in the last year. So we are really appreciative and grateful for those conversations. Again, our concerns are fairly similar to my colleagues from ACLIC and her testimony that she highlighted.

I would also point out that we do have some questions and potential concerns around the timing of the Bill, as there's a considerable amount of work that's being done in this area, as you all know, within the last couple of years.

Specifically, we are looking at the requirements for plans and insurers to cover services that originate from 988 calls in legislation that was passed recently, as well as care court, as well as the imminent implementation of the children and youth Behavioral Health Initiative, which will alter the way that children and youth access care. And so these mandates require plans and insurers to cover a variety of mental health and substance use services without prior authorization or zero cost share.

So while all of these various programs are kind of coming together relative to the delivery of mental health services for children and youth, I think we want to be sure that we're mindful of all of those programs in addition to potential other considerations moving forward. So with that being said, we are opposed to the Bill, but again, look forward to continuing to work with the author and sponsors on a path forward.

Okay, thank you very much. And while we have them here, I'm going to ask the secretary to call the rolel please, so we can get a quorum.

Senators Eggman here. Min here. Glazer. Gonzalez here. Grove. Hurtado. Limon. Menjivar here. Roth. Rubio here. Wahab here. Wiener here.

We have a quorum. Thank you very much. Okay, anybody else speaking in opposition today, please?

America's health insurance plans and respectful opposition.

Thank you. Thank you very much. Anybody else okay, thank you very much. Senator, would you like to address the issue of multiple programs all coming online right now?

Every policy area I'm in, we hear from the opposition that we passed some other bills, so don't pass more bills in this area. This is a very specific issue of children whose families have health insurance and they have a mental health problem, and the insurance company is denying coverage, and they don't even realize that they can invoke an independent medical review. All this does is invoke it automatically. We actually made an amendment in response to feedback to distinguish between life-threatening and non-life-threatening diagnoses.

So for the non-life threatening, it'll be an automatic preliminary review by the insurance company so they can correct any error that they want to correct. And for life-threatening, we want it to go to that review quickly. So this is a very specific issue that does not in any way conflict with other policies we've adopted.

Okay, thank you. If there are no other questions from any other Members, would we take that as your close, Senator? Yes. Okay, thank you. And we have a motion by Senator Gonzalez. If secretary could call the roll. I'll read the motion, please. And you're right, there were amendments that you accepted. So we're going to do pass as amended and re refer to the Committee on appropriation.

Yes, I accept the Committee's amendments. My apologies for.

That's right. My bad. Thank you. Okay, so that is on call. Again, we encourage Senators to come as rapidly as possible, and Senator Wahab wanted to make the motion on Senator Umberg's. Do you want to vote on 294? I'm sorry, I thought we voted. I'm going too fast. Let's vote out more than last.

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

That's on call. So that Bill is on call. Again, we encourage Members to come. And on SB 26, Umberg, Senator Wahab made the motion, and that motion is do pass as amended and rerefer to the Committee on Appropriations. Secretary, please call the roll.

Senators. Eggman aye. Min. Glazer. Gonzalez aye. Grove. Hurtado. Limon. Menjivar. Roth. Rubio aye. Wahab aye. Wiener aye. On call

Okay, that bill is also on call. And next up, we have Senator Wahab with SB 402.

All right, thank you, Chair and members. I first want to thank the Health Committee for working with our team on this particular bill. I do just want to say that we will be accepting the amendments as discussed with the committee. And specifically, I do want to highlight that SB 402, the appropriate response to mental health crisis, addresses deficiencies in the current law related to mental health crisis interventions and specifically the initiation of 5150s.

Specifically, the decision making process phase of initiating a 5150 or a 72 hours hold does not always include the active involvement of mental health experts, which leads to poor outcomes for the individuals in crisis and their communities.

In fact, if you take a look, Prop 63 was passed in California by voters and resulted in community based organizations being able to provide prevention and early intervention care specifically to make it more robust that communities of color can address some of their community needs more directly rather than going through a hospital and so forth. Many of these agencies hired licensed marriage and family therapists, as well as social workers and LPCCs to do the work for mental health and early intervention.

These individuals develop a rapport with the individual community members, their families, and much more. Many of them operate as a case worker and provide services to them and understand when they have to go to a doctor, what types of medication they're taking, and much more.

With Prop 63, we have discovered, including myself as a board member of one of the agencies that did a lot of this type of casework, was that there was a limitation when an individual was becoming a little bit more unstable, that the marriage and family therapist or the social worker or so forth would have to call 911 or a police officer to initiate the 5150 hold. This is obviously very problematic in many ways.

Specifically, our current framework places undue pressure on law enforcement to initiate 5150 holds, resulting in potential delays as well as police officers making mental health assessments without their background, casework, and knowledge of that particular individual. SB 402 seeks to address these issues by expanding the category of authorized initiators of a 5150 allowing licensed mental health professionals like licensed marriage and family therapists, LCSWs, and LPCCs to initiate the 5150.

Licensed mental health professionals within these organizations are limited in their ability to fully support their clients as is, and this hopefully addresses that particular concern. We are talking about having more professionals who have established trust with the clients and communities. SB 402 aims to support these frontline licensed mental health professionals and their clients with a strategic expansion of who may initiate the 5150 and if it's really needed. Additionally, with these amendments, SB 402 will also improve and increase reporting requirements regarding 5150s as LMHPs report and police do not report necessarily the 5150s. I respectfully ask for an aye vote.

Okay. Anybody speaking in support of this bill today? Seeing none. Anybody speaking in opposition to this bill today?

Good afternoon, Madam Chair and Members. Michelle Cabrera with the County Behavioral Health Directors Association of California and first, I want to acknowledge and thank the Chair as well as the Committee staff for the amendments, which we are still in the process of reviewing with our members. We think that the provision to require that individuals, licensed mental health professionals, that they still be authorized by the county is an important one. County designation ensures several things that I want to emphasize and underscore.

The first is that not all mental health professionals who are licensed in the State of California are currently actively practicing, and this would, in its original version, have given the ability to placeholds regardless. They also don't all work in crisis, and so they don't understand necessarily the specific components of crisis. The reason why we think that the designation process is so important is we require training as well as, in most cases, passage of a test. And then we do consistent oversight and monitoring of these clinicians.

In L.A. County, for example, we have 4,200 individuals who are all licensed clinicians who have been designated by the county of Los Angeles to put people on holds. They all have to go through training. They all need to pass the test. And so it's really important, both for our own sake, to ensure that those individuals understand this power and authority, but also for the reporting provisions.

Senator and Chair, you passed a Bill that recently that ups the ante that requires counties to report certain information, or else we're penalized. If individual clinicians are not under county designation and under the oversight of counties. We have no means to ensure that those individuals are tracking because we may not know who they are and that they've ever placed a hold. And so it creates a bigger problem there.

We're also concerned about potential liability for providers and them not understanding that if someone dies by suicide or hurts someone else, that they could potentially be liable if they did or did not put somebody on a hold, essentially. So, for all of those reasons we originally opposed the bill, we're still looking at the amendments to ensure that they have that sort of safety net of county designation and appreciate so much the Committee's work in helping to move this bill to a better place. Thank you.

Thank you, Ms. Roth.

Good afternoon, Madam Chair, committee members. Deb Roth, Disability Rights, California, we are here in reluctant opposition. We think the author is working on something very important with an intent that we support. We definitely think crisis response will work better if the role of law enforcement is reduced. We thank the author for meeting with DRC twice, and we look forward to continued meetings in the future. This morning, Senator Wahab agreed to convene a stakeholder group to work on the vexing issues presented by the bill.

Generally speaking, we oppose any bill that expands involuntary treatment. And unfortunately, with this bill, as the Senator said, you end up having to call 911. And that's one of the things she wants to change. And we think that even with this bill, there will still be calls to 911. And if through the trust in that relationship that a therapist has with a client, the client can be convinced to go voluntarily; then you don't need an involuntary hold. Don't need that 51/50.

But the default under the bill in expanding the 51/50 authority, the default then becomes 51/50. But then we think it's unclear just how this is going to play out in real time because we think a therapist, if a therapist thinks a client is in crisis and that therapist has a history with the client, hopefully, there's trust in that therapist-client relationship. It will lead to the client being able to get care on a voluntary basis.

If the therapist thinks it has to go down the road of a 51/50, we don't see how they're going to transport a person who does not want to go to the hospital, to the hospital. And we think law enforcement is going to get called, and that's how it will play out in real-time. We raised the issue with Senator Wahab this morning about just when a therapist would be able to exercise this authority.

Although it is true that therapists are mandated reporters for things they witness at any time, I think the Senator agrees that this particular 51/50 authority should be limited to situations where the therapist is performing their usual business functions. So, we are not prepared today to suggest any language, but we look forward to participating in a stakeholder convening. We would be really happy if we could not only remove our opposition but also move to a support position. Thank you very much.

Thank you very much. Others speaking in opposition come forward at this time.

Cal Voices in respectful opposition and conversation with the author. Thank you.

Andrea Rivera, on behalf of the California Pan-Ethnic Health Network, we are opposed to the version of the Bill that is in print and are reviewing the amendments. Thank you.

Thank you very much. Okay. As we've had a lot of conversations, we've worked a lot on this bill. And so what it now does is say the county is the designee to decide who those people are. And you cited 4,200 in L.A.. And I think you're going to work on some more information for me for some other counties.

And I respect where the Senator is trying to get, and I think that is a conversation that we need to continue to have ongoing about trying to get law enforcement out and licensed professionals in. But at this point, the bill will say that counties have the authority to designate people. Any other questions at this time? Senator Grove.

Thank you. Thank you, Madam Chair. I do have a couple of questions. If it's okay, the author to go directly to the witness.

Sure.

Through the Chair, you talked a little bit about how that plays out on the ground. I get where the author is trying to go. We have people on the streets.

I've seen bills come through this building in this very committee where parents are pleading with us to allow them to be able to provide medical, I don't want to say mandated medical but mandated medical because they would show us pictures where the individual is lucid and normal and had a job, and now they're on the street naked and they can't function. They're not functioning in what they is a safe place or a safe humanity place.

So I understand where the author is trying to go, but I guess the questions that I have, I want to know how it plays out because the way I see it, I'm not a licensed professional, but the way I see it is you're treating someone, you think there's an imminent threat, or there's something that happens, and you are going to arrest this man because he's, no offense, but you know what I mean? Is that what would happen?

Or are you going to pick up and call law enforcement 911? And you can call law enforcement 911 now? I understand. Or not?

He's not a threat.

You're very close to it.

I think that was our initial question when we saw the original version of the bill was: what next? Right. Once you've theoretically put somebody on a hold, and this goes to Disability Rights California's comments: you've determined that this person is at such a high risk that they need to be evaluated by a trained clinician to determine whether that temporary hold needs to be extended and whether involuntary treatment is needed on a longer basis. Because sometimes these episodes are sporadic and or temporary. Right.

Any person could have suicidal ideation. Right. It's not just the person who ends up on the street. 51/50s are far more common. Right? People have terrible moments where they contemplate death by suicide.

And so it is assumed that there's a broader category of people who might fall into that danger to self or others category, and then there's a much smaller subset who may need more significant ongoing involuntary treatment in order to make a determination about which category you fit into, you need to be transported to what's called a designated facility, a place where those professionals who can do that more thorough evaluation, who have been trained are.

And to DRC's point, you need to be able to physically take a person to that place. And so the real underlying problem is around that restraint and transportation issue, which is why the law enforcement question is a challenging one. Right?

There are very few individuals and entities that have been imbued with the powers and the authority to restrain someone against their will and physically move them from one place to the other. So, unfortunately, that is still a problem. If we widely expand the net of who's given the authority to put someone on a hold, those people, then how and in what way do they do something about that hold?

I guess my question is, is it the expectation if you are a licensed professional? Is it the expectation that you do it under this bill, you transport them

This bill leaves that question entirely open.

And there are only so many people who can do that. Right. So it's law enforcement and certain EMTs who are trained in that way. Even most of our mobile crisis teams can't do that.

Okay.

If it does go to the county designation under the Chairs, I'm assuming the committee's amendments, is there like a standard operating procedure or who the county can designate? Is that already in place?

Yes. That's part of the training. It's understanding; what are you doing when you put somebody on hold? What does this put into motion? What does it mean for you as a professional? What does it mean for the individual, and what do you do next? What are the steps that follow? Understanding all of that is really important when it comes to this kind of very high-risk situation, and it is high risk for everyone, for the individuals involved, and for the community.

Thank you. The last question I have, Madam Chair, is I look at it from two causes. I'm sure you're very capable in your job, but if you have a 200-pound client that's a male, I don't see how you're going to apprehend that client and take him in. That's where I see this going. But I could be wrong. I think you pick up the phone and call 911, but we want to eliminate 911 and law enforcement. So, I see the conflict. What about the liability piece?

If the bill passes and it gets signed, where's the liability lie? Does it lie with the individual therapist? If they make a determination that they should go and then something happens to that individual, or where does it lie now?

There's a lot of murky liability tied up in this, in the sense that if you're a clinician, say, and a patient in the course of your visit says something, and you determine, "Okay, they may have mentioned, I want to die, but do I think that this is credible? No." And then that person dies by suicide. The family could say, "You had the authority, you had the power to put this person on a hold, but you didn't.

And now my loved one is dead." So they could go after that person individually.

Okay, thank you.

So can I address some of the questions you had?

Yeah, I'll turn to you next, ma'am. Sorry.

Thank you. So, you raised a couple of good questions. Right. And I want to be very frank. The original bill's intent: one, this does not eliminate police officers from making a 51/50 call at all. Right? This expands it to professionals who are already dealing with these individuals. They are designated by their individual counties through whether that's certification training and so forth. Right.

So we want to make sure that we are ensuring that the individuals working with these communities are as trained as possible and following the guidelines. Number one. Number two is that in the city of Hayward, we have initiated a lot of effort around this specifically to have an appropriate response to crisis calls. And I want to be very clear. I have worked on this particular issue for a number of years. One, we did a survey within our own internal police force.

Police overwhelmingly do not want to handle mental health calls nor homeless calls. They are not social workers. They do not have the qualified training to deal with a mental health evaluation or anything like that. They are usually called and then work with somebody to make that assessment, including the negotiation teams, the crisis response teams, and much more. However, the individuals that are working at community-based organizations, individuals that have their other types of organizations that work in this space are having a significant amount of difficulties.

So, to your reference of a family member begging somebody to please, my mother, my father, my brother, my sister, my loved one is struggling, I know that they have issues, but their medication is off, or they're not taking it anymore or anything like that. Please help. That is happening today. And when they call 911, because 911 have other issues to take care of. Robberies, rapes, murders that are considered priority one calls. Right. They will triage that as to what their priority is.

I have gone on a number of ride-alongs with my police as well, and oftentimes, we were on a call where police stated that there was an individual that was on the train tracks. Right. You don't know exactly what's happening on those train tracks. It's in the middle of the night. It was midnight, and the call was, "I don't know if they're trying to commit suicide or do something weird."

And police are afraid of that individual that they're responding to is interested in committing suicide by cop. Right. Which makes the police officer scared a little bit, too, and have a heightened a little anxiety when they're approaching those calls. We also know domestic violence calls are the riskiest calls. And so, in our city, we ensured that police were still responding to domestic violence calls. I will say that this does work. So far in the city of Hayward, it's in its third year.

As far as transportation, I do want to be very clear. We are focused on policy here, but as a procedural move, we have initiated a lot of things, and we've seen what works and what doesn't work. Firefighters are able to transport people as well. They do not carry a weapon. They are able to respond in a local city a lot faster than police because they are not on as many calls. 61% of 911 calls in the city of Hayward are actually about health care.

So when you call 911, you're saying, I have a heart attack, I'm not feeling well, things like that. And 39% are related to crime. Right. Or some type of issue that a police officer attends.

So I want to prioritize that and just explain that the communities that are largely affected do not go to the Doctor as regularly, do not have therapy as regularly, may not even know that they have options or even immigrant communities where mental health stigma and mental health across the board is not really well understood, appropriately discussed or anything like that, including in my community, there have been conversations that we have to be culturally appropriate and so forth.

But there are communities that believe that if you have depression, you should toughen up. There are communities that believe that if you're schizophrenic, you are possessed by the devil. There are communities that are not well equipped to handle this, and they trust the community-based organizations that they may have a relationship with in their individual cities or counties and so forth, that speak their language, and so forth. A lot of these therapists of different backgrounds usually want to work and support their own communities.

That's one piece. To the commentary that was made about licensed clinical social workers, or LMFTs, that potentially do not necessarily have the training, across the board, there's about 3000 hours that they have to have to get licensed by the state. So they do have a significant amount of training. And, of course, we've stated that from the county perspective, whatever other training or clarification they want, of course, we will oblige as happily as possible. However, police officers don't have the same amount of training regarding mental health.

As far as nonprofits, they can simply get a grant and retrofit a vehicle, a bus, a van, something like that. But we have also seen a lot of collaboration with the hospitals, with the ambulance service, with much more.

So I think that, again, this is a start to an issue that we clearly see for families that are struggling, that are reaching out, that do have their individual loved one in some type of agency that has actually spent a year with them, two years with them, seen them do well, and maybe their meds are off or something like that. And the people that voluntarily come, they voluntarily come to the individual that they trust, that they've been working with.

And again, when we talk about paranoia or schizophrenia or anything like that, some of these individuals have a natural opposition to authority. And that's what if law enforcement comes into play, not that they shouldn't come into play, in some instances, they are a little bit more agitated. Whereas with their therapist, their case worker, their social worker, things like that, they may willingly and calmly actually go. So even if they are 200 pounds, 300 pounds, six foot five, six foot four. So we have seen this work.

I would like to initiate this on a statewide level. And obviously, I have to do it through an umbrella tier, tier, tier, tier to get to exactly what I need in the state. But I will say that this has been largely successful. It is called the HEART Program in the city of Hayward. I urge everybody to take a look at it. Our firefighters fully support it, as well as our therapists. So happy to address any other concerns.

Senator Gonzalez.

Oh, sorry. Thank you very much. I do. I think everybody on this dais realizes that we have a problem. I took a call yesterday from an Orange County resident who is- her son is suffering from psychosis, and they can't do anything about it because he's 20 years old. I think we all realize a problem. I'm just nervous about the. We make decisions here on a 10,000-foot level, but it's hard for me to digest how this is going to work on the ground.

So I do want to look at your program that you have, the HEART program. Thank you.

Thank you.

And again, Senator Grove, this bill just simply says that the county is responsible for designating people.

Thank you very much, Madam Chair, and thank you for bringing this forward. I think what has been said is what I agree with as well. Absolutely.

We see a problem with the law enforcement aspect of it. How do we lessen that? That's what we all agree on. I also too have a HEART program in the city of Long Beach. It's a pilot program, and we know that it's going to have an end date very soon.

So I'm glad we're having this discussion, but maybe this is for your witnesses or if you have the information, what county, outside of those sort of hodgepodge pilot programs that we hope would be sustainable, the county, as we're defaulting with these amendments, with the county designation, are there any gaps currently? I mean, you talked about the types of, obviously there are lots of gaps.

I know. Right. But do you talked about the types of licenses, licensed therapists, some that might not be active? Do we still see that within the county?

So I will say that even, for example, a person can get licensed and graduate and go through the graduate program, but some people want to earn more money. Right. And so they have their license, and they end up being an elected official instead of working in social work or therapy.

I will say that oftentimes when we are working on an amendment together, we had this conversation earlier today, so we are not taking it in this particular committee because it's a different amendment, to clarify that language as to when these individuals can potentially do it. So there are plenty of gaps in mental health spaces when we talk about policy, the county, the cities, emergency health, and so forth.

But specifically with this county designation, because obviously this is what it may change later. Obviously, as you're discussing, and you're going to have meetings with everybody?

That's the current structure as it stands today.

Yes. But perhaps, can I ask your witnesses as well?

Not my witnesses

Through the Chair? I'm sorry, the opposition.

These are opposition.

My apologies. It's been a long day. Do you have any additional feedback on that? I would just like to get sort of a larger picture on what that.

And I will say just in working on this bill, we've asked Ms. Cabrera if we can get a number of every county, how many that they have that are designated. She said L.A. County is 42. And so we've asked for that information for every county. 4200, 4200.

4200 Clinicians designated in L.A.. Yeah,

L.A. County.

L.A. County. Yeah.

Those are all county workers or non-county workers.

So it's a combination of county and non-county, but they would be contracted providers nonetheless. And the contract is actually important because, again, that goes to how we can ask or compel them to report to us or give us what we need to be compliant under LPS. If it's an individual practitioner, solo practitioner, has their license, is maybe seeing people private pay or whatever, our relationship to that provider is nil. We don't have any idea how we can -

- that they exist, that they're putting people on hold. We have no leverage to say, "Hey, if you don't report this, then we're going to get fined." But they don't have any need or desire necessarily to report to us. So those kinds of very practical issues loom large for us. Aside from the risk and liability concerns, I would say in terms of the backgrounds of people who are designated by counties, it does vary and so does the availability of these clinicians county by county as well.

So in some communities, we just don't have very many licensed clinicians, period. So you'll see very low numbers in those counties.

Yeah. 4,200 for a county that has 10 million people.

Yeah.

So we're trying to hopefully expand and do more outreach.

However, that's just individuals. They also have 60 hospitals that have designation status. So it's a bigger net, I would say, in L.A. County.

Yes. And I'm also looking at some of their LPS criteria that hasn't been updated since 2016. So we've got some work.

We're updating a lot of it.

And to your point, also we have. Okay, so, for example, each county handles it very differently. There's no uniformity county to county. I represent multiple counties. They don't handle it the same way. And at the same time, those medical facilities, it's based on the delegation of authority of their psychologists. So it's not every single individual that works there, even with the credentials that they have. So it's limited in some counties significantly, maybe expanded in some counties significantly.

Psychiatrist and I would just say, as the only licensed person sitting up here and who did have 3,200 supervised hours and sat for all the tests, you don't go over step by step how to do a 51/50. I mean, it's a different kind of work. Right. Melanie is an MSW. Right. She probably hasn't worked in direct practice for a very long time. Right. So, just to say, everybody who's got one can do it.

Right. It's not covered in school. If you have a placement in which you do that kind of crisis work, then you'll get experience at it. But if you don't, then you're not going to get that kind of experience, which is why this bill kind of, again, understanding that there's a bigger issue out there. But this bill just narrows it down to say which is existing, that counties are the designated person to authorize who can do it and who can't.

One last thing I will just add, just to think about as you're discussing this, the city of Long Beach has its own Health Department, so even more cumbersome for us to get mental health data. And so as you're thinking about the counties, you should think also about the jurisdictions like the four cities across the state that have health departments and that also have to work directly with the counties but may not be supported as much as they should be in mental health and in this realm.

Yeah. And sadly, we also know counties don't necessarily, not all of them prioritize mental health as well. So there are some counties that literally, it's very minimal funding and much more. So we have significant concerns that we have to address moving forward.

Okay. Senator Menjivar.

Thank you, Madam Chair. I missed a big chunk of this conversation. I don't know if this is repetitive, but I had initial concerns. It sounds like a lot of the people in the dais had some of the similar concerns on this. Some of the concerns for me is the unintended consequences in terms of what happens in real life. Don't know. Again, if this was talked about, if a therapist then puts me on a hold, do I then wait on the sofa? Who comes in?

Does the PET team get called for this? There's not enough people on the PET team. Those are some of the things I'm still concerned on. In the short conversation that I've heard. I haven't heard anything that's addressing anything like that. Again, I agree with everybody here that I, too, want to remove law enforcement from these kind of calls.

I do want to make sure, I don't know if there's capacity in this Bill later on to add just the process of what it would look like after someone puts someone on hold. Does the therapist, I know they don't, but does the therapist then drive this individual to their local ER?

So, Senator, we did talk about this.

I figured. So I'm just voicing it. I'm going to be voting Aye for this Bill, but reserving my right that once we get it to the floor, it's more robust.

So this Bill simply expands the designation of who can initiate a 5150 right now, even with law enforcement. So, for example, there's a case of an individual who had schizophrenia, and their family members were working with the strike team in L.A., and they were unable to get them to have a hold and placed on hold. Right. Even though the therapists and so forth that were on that team specifically said, yes, this individual is not stable and so forth.

It took roughly two weeks because the strike team had to go out multiple times and still couldn't place them on a 51/50 hold. They kept calling law enforcement. By the time law enforcement came an hour away, 2 hours away, had other priorities because law enforcement handles mostly crime-related issues, this individual would leave. You can't hold them there right now.

However, we have seen other types of efforts where if a 51/50 is placed on an individual and they are, one, willing to work with their particular person, that they're talking to that therapist that they have a relationship with, or there is no sense of authority over that person. For example, a law enforcement officer with the police and a gun and so forth, they are more willing to go with the individual. We've also talked about.

My definition of 5150 is someone that doesn't want to go.

Yeah, technically, it's a little bit of both in the sense if I'm talking about the process. No, the process. So we're talking about policy of initiating the 51/50. But I also want to say that the questions so far have been about process. So what does the nonprofit do? What does the therapist do? So forth. Right.

So I guess my question, if the strike team is on the street and if they had the ability right there and there to put them on hold, they would still have to wait two weeks because they themselves can't do anything past that. Right?

No. So they have not been able to initiate the 51/50. That is the problem.

Even if they do, even if they said in the moment I have the authority, I'm now placing you on 51/50. That's as far as it would go.

Not necessarily, because from a process perspective, again, this would be process. The organization that employs the strike team could also have the tools for their particular employees to be able to carry out their job. So that could mean, and we've talked about this, for example, in the city of Hayward for us.

If I could interrupt you for a second, because I think what the Senator is saying, you've told us that repeatedly that those are practice issues. I think what she is saying is before this Bill would need more work to be able to address more of those things, before people would feel comfortable with it. This Bill simply says the county is the designee to decide who can institute a 51/50 and who cannot.

If we're saying that not all counties look at mental health as a dire situation, and we're giving them the ability to then designate whoever they want to designate. Isn't there a place to be worried about that?

It's existing law, Senator.

Oh, that's right. That is true.

That's how 4200 people are designated.

If you don't mind. My answer, every single county is responsible for the delivery of specialty mental health and substance use disorder services under contract with the State of California. And so every county, of course, has a significant set of services for people with severe persistent mental illness. I would say the degree to which each of those counties has extra county General Fund that they're able to add on top of the funding that the state and Federal Governments provide is variable.

And some counties are very cash-trapped. And so there is not that margin, you know, we do see some counties are in a position politically to pass taxes, for example, that help to augment their mental health services. Those tend to be in the Bay Area and those sorts of places. So there are differences across the state, and a lot of that has to do with resources.

Right. And that's some of the work that we've been doing the last couple of years is requiring more data, requiring more transparency and information on 5150s and what the treatment was, what the outcome was.

A lot of those things that we weren't collecting in a good way before and doing anything with that data, that's some of the things that we've been working on the last couple of years to make that process, which is what Ms. Cabrera said, which just designating anybody would make it more difficult, but to be able to get real numbers and outcomes on how every county is doing and if who needs help and who doesn't.

So if there are no other questions, would you like to close, Senator? Oh, Senator Rubio.

Sorry. This is just based on everything that. I heard here, because I think we all have the same intention of trying to take care of those that are, you know, or family members are struggling. But I think I heard you say you have a program in Hayward, and I heard the Senator from Long Beach say that she has a program in her jurisdiction. I think we just shared. You have 500,000, which is a big community. Yours is about 160,000. I'd like to see, and I know we're talking about data collected, like, for someone that has smaller communities.

And I think I heard you say that it works well, I'd like to see maybe in the future a way to condense this information for local agencies, jurisdictions, counties, to be able to go and see what the best practices are. Because from hearing you, as well as hearing the Senator from Long Beach, it feels like the answer is there somewhere. Right?

But for someone, just writing from scratch may be difficult. So just a thought of maybe in the future making some kind of website where we can go to for information so that we can refer our local communities to go get data. But thank you. And I was going to say I had a lot more questions, but given that it's the Senator's birthday, I decided I'm going to go easy on her. Happy birthday soon.

Thank you.

Okay, any other questions or comments? Seeing none. Senator, would you like to close? And, Senator Rubio, I have asked Ms. Cabrera for that information, not for the website, but just for, like, tell us what every county is doing. But I would encourage everybody to call your local counties and say, how many people do you have designated? Can I see your process? Because they all have to have a process for it. Okay. Would you like to close?

Thank you. Well, one, I just want to thank the witnesses here. We have been in conversation and we will continue our conversations. I will say personally, mental health is incredibly important to me. I have stated to even the opposition that I will continue to work in this area. We do have a lot of different gaps at the state side, at the county side, even the cities, and emergency response. There's not one thing that can solve every single problem.

And I think that for me, this Bill is a start to at least expand who are on the front lines, working with communities in need. And I respectfully ask for an Aye.

Thank you very much. And the motion? Do we have a motion to move the Bill? Moved by Senator Limone, and the motion is do pass and re-refer to the Committee on Judiciary. Secretary, would you call the roll?

[Roll call].

We'll hold the roll open for any absent Members. And now let's move back up to nine. Sorry, nine. SB 26. Senator Umberg, mental health professions care scholarship program. Secretary, please call the roll.

[Roll Call]

That's 10-0. Hold that open for a minute. And then finally, SB 294. Senator Wiener, they do pass and refer to the Committee on Appropriations. Secretary, please call the roll.

[Roll Call]

Okay, we'll leave that one open and encourage Senator Grove to come on back. She's on her way, I think. But then I would thank the rest of you for our first Health Committee hearing of 2024. 11 is out, the roll is closed. SB 294. Nine to two, that Bill is out, the roll is closed, and on SB 402. 9-1. That Bill is out and the roll is closed. And this concludes the Health Committee hearing.