Assembly Standing Committee on Health

Additional testimony will also be in person and limited to name, position and organization. If you represent one, all testimony comments are limited to the Bill at hand. We do not have quorum at this time, so we will begin as a Subcommitee. With that, we also want to recognize that we have a substitute Member. Thank you. Assembly Member Juan Alanis will replace Assembly Member Vince Fong for today's hearing only, per the letter from the speaker.

With that, we will move to our first item, which is AB 1830. Sorry, Dr. Arambula, which is AB 1842. Assembly Member Reyes Healthcare Coverage Medication Assisted Treatment thank you so much. Ms. Reyes, you may begin. Can you put your mic on? Is your mic on? Go ahead. Thank you.

The mic is on. Thank you. Thank you, Madam Chair and Committee Members, thank you for the opportunity to present AB 1842. This Bill would prohibit commercial health insurers from imposing prior authorization rules that create barriers for accessing medication assisted treatment. Medications such as buprenorphine or long acting naltrexone can significantly improve treatment for many substance use disorders by treating cravings and withdrawal symptoms. However, medication assisted treatment has been underutilized. Almost two thirds of commercially insured persons in California with drug or alcohol dependence do not initiate treatment.

Prior authorization requirements create unnecessary barriers that delay or interrupt access to effective treatment. AB 1842 is an important first step that will reduce overdose rates and save lives. Here to testify in support of the Bill are Dr. Aimee Moulin and Dr. Rodney Borger. Dr. Mullen is a Professor of emergency medicine and Division Chief of Addiction Medicine at UC Davis and Director of the California Bridge Program.

Dr. Borger is Chairman and medical Director of the Department of Emergency Medicine at Arrowhead Regional Medical Center for San Bernardino county in the City of Colton.

You may proceed.

Thank you. You in know addition to supervising the emergency Department at one of the state's largest emergency departments in San Bernardino, County, I also supervise the corrections medical system for our county, as well as four large primary care clinics and opiates continue to ravage our community. Deaths and overdoses of both hardcore users and young teens experimenting for the first time are a norm. In my daily experience, it even drives criminal behavior in our area.

And as an emergency physician, I see the toll firsthand that addiction and overdose takes on patients and families. It's not only the person that's involved, it's the entire community. It's fathers, brothers, sisters, employers are all impacted by this big problem at Arrowhead. We've been treating folks through the California Bridge program very effectively. And California Bridge is a program that the state's been funding where addicts or people with addiction issues can present to the emergency Department, where they've been presenting for years.

But we haven't had an ability to get them connected to community resources or treat them. We've been able to do that, and we have one of the larger programs in the county. The good thing is if a patient has medical, you can get them connected with a prescription and community resources and an inpatient program. If somebody has insurance which you think would make things easier, it actually makes things much more complex.

I want to talk, give you a story about two patients that I've treated in the last year. The first patient is a patient who had medical who became dependent on opiates because of a back injury at work. He wasn't disabled from his back injury. He was disabled from his addiction. He was completely cut off from his family, and he was able to get through the California bidge program and is sober today.

Then I had another patient who had private insurance who we managed to get him into a 30 day inpatient rehab. He finished 30 days. He was sober. His family was really appreciative, and he couldn't get his prescription. When he was discharged from the inpatient rehab, they said it's going to take about two weeks.

He relapsed during that two week period and had to present back to the emergency Department, where we dusted him off, got him back on some medication, got him back, and restored to his family. The insurance company paid for the ED visit the second time. They didn't save any money. And in my experience, of all the people, they've never refused payment for this medication for this indication. All it did is put a two plus week barrier in the patient's care that's completely unnecessary. And please continue to support this Bill. I think it relieves a lot of unnecessary burden and would really be helpful. Thank you.

Thank you. And second witness. We have three minutes each.

Thank you. I'm Aimee Moulin. I work for the CAL and Bridge program, which is our program that works with over 270 of our acute care hospitals. And we're providing access to patients with opioid use disorder to life saving medications like buprenorphine. I do want to take a moment to thank the bravery of Assembly Member Reyes for coming here and trying to pronounce buprenorphine multiple times. So thank you. It is a remarkable medication that works as a partial opioid.

So it treats people's withdrawal symptoms, it treats their craving, but it does not cause euphoria like fentanyl. It does not cause people to stop breathing like fentanyl. It really just helps them to feel better and to feel normal. But with fentanyl, it's a little bit harder to start someone on buprenorphine because you have to be in withdrawal.

So we are able to start someone on this life saving medication in our emergency departments, and then if they can't get the prescription filled, they go back into withdrawal, often relapse. We can lose them to reuse, but we've lost that really important opportunity to connect that person to treatment and to lead them on their road to recovery. So we often lose people in that delay period where we're kind of trying to deal with prior authorization.

So really appreciate your attention to this Bill and your attention to the overdose crisis and fentanyl. And we think that this is a really key step in helping to get people into recovery. So thank you very much and happy to answer any questions.

Thank you. With consideration, we will take a moment to just establish. Quorum secretary, can you take the roll, please?

[Roll Call]

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

Thank you. We have quorum. We'll move now to additional witnesses in support. Please state your name, organization and position only.

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

Thank you, Madam Chair. Tim Madden, representing the California chapter of the American College of Emergency Physicians, in support.

John Drebinger with the Steinberg Institute, in support.

Thank you, Madam Chair. And Members. Alex Kahn, on behalf of the California Chronic Care Coalition, we just want to apologize for the tardy letter, but we're here in strong support and look forward to having a letter in short order.

Good afternoon, chair, Members of the Committee. Ryan Brigodeau, here with the California Hospital Association in support.

Thank you. Good afternoon, chair Members. Dylan Elliott, on behalf of the California Academy of Child and Adolescent Psychiatry and the California State Association of Psychiatrists, in support. Thank you.

Good afternoon, Madam Chair. And Members Mari Lopez with the California Nurses Association in strong support. We too, have a tardy letter. Apologies.

Thank you. Are there any primary witnesses in opposition? Thank you. We'll allow two witnesses at three minutes each to present testimony. Please go ahead.

Good afternoon. Chair and Members of the Committee, Robert Boykin with the California Association of Health Plans. Regrettably here today in opposition to AB 1842, this is obviously an important issue. Health plans have heard the concerns and are constantly looking for ways to streamline the process while protecting patients and delivering high quality care. However, this Bill seeks to prohibit health plans from requiring prior authorization or step therapy for several drugs when treating someone with a substance use disorder.

It's important to note that some of these drugs still require a significant detox period, which prioritization is vital for. This has the potential to remove any check on possible adverse reactions from other medications. From our viewpoint, utilization management is necessary for patient safety and cost effective care. Also note that this is one of several mandate bills that the Governor vetoed last year because of cost concerns. Regrettably, most of those bills are largely unchanged this year.

Last year, the governor's veto message regarding AB 1288 stated that utilization review is an important tool for containing health care cost, protecting patients from unanticipated billing, and ensuring medical necessary care. Unfortunately, AB 1842 does not address any of those points raised in the veto. For the reasons stated earlier, we regrettably ask for no vote on AB 1842. Thank you for your time today.

Please go ahead.

Madam Chair Member Stephanie Watkins, on behalf of the Association of California Life and Health Insurance Companies, in the interest of time, I will echo many of my colleagues comments. There will be many bills, and we have seen many bills in the Legislature on prior authorization and step therapy. I think that, as my colleague mentioned, I think there's an open interest in dialogue about having a conversation about how we can address any concerns.

I think it's one thing that came up is the conversation around something taking two weeks to fill a prescription. I certainly would think that our Members would be concerned about that. Right now, there is a requirement that with respect to prior authorization for RX, it's a 24 and 72 hours time period of a turnaround. If there are issues that are happening outside of or that are anomalies, we would be more than open and willing to have those conversations. Look forward to having those.

I think this is an important piece of the healthcare conversation to make sure people have access and timely access to important medications. But we are concerned about the removal of prior authorization or step therapy. And also, I think I would point out the original Bill did reference appropriate guidelines for prescribing, and I think that's also an important piece to ensure that people are getting access to the right drugs at the right time.

So for those reasons, we are opposed today, but certainly look forward to the potential to have an open dialogue if the move Bill moves forward today. Thank you.

Thank you. We'll now move on to additional witnesses in opposition. Please state your name, organization, and position.

Madam Chair Members. John Winger, on behalf of America's Health Insurance Plans, would just echo the comments of CAP and ACLU.

Seeing no other witnesses in opposition, I will bring it back to the Members of the Committee for any questions. Dr. Arambula?

Thank you, Madam Chair. I'm going to begin with an appreciation for assemblymember Reyes for bringing this Bill back. It's important for us to address the crises that we have before us as a state, and I'm grateful that you brought both Dr. Borger and Dr. Mullen here, who are emergency physicians on the front lines who are experiencing that crisis, and we should listen to that lived experience.

I simply will add my own, having practiced for 10 years, having worked at an addiction research and treatment facility, and knowing the importance that these medications have in helping to save lives and ultimately in saving us money as a state, as a system, by providing the right treatment at the right time. But I look forward to supporting this measure today and just want to thank you for bringing it forward.

Any other comments from Committee, Mr. Patterson?

Thank you. I think if, just to go to what the health plan said, I think if somebody was in crisis, I think waiting even 72 hours is kind of a long time when they go into emergency room. I mean, I'm hearing obviously from our doctors and hospitals all the time about how full they are, and we all know that. But if there were some proposed amendments or something that said, hey, look, maybe sort of the initial was covered or something like that, that could make sense.

But I supported this last year. The governor's veto didn't sway me, so I'll be supporting it again today. But I would be open to, because this won't be the first mandate Bill that comes up this year, some kind of conversation around when people are in mean, I think especially in the emergency room, we got to get to them and address their issues. So I'm supportive of this. Thank you.

Mr. Jones Sawyer.

I just want to quickly understand what we're ultimately voting on because there's a support, if amended. Are we just straight ahead? Are we not doing the amendment?

What are we doing so this is due pass to approps

To Approps. Okay. Thank you.

Seeing no other comments from Committee, Ms. Reyes, you may close.

Thank you, sir. Thank you so much. I just want to remind us that this is for prior authorization on medication used to treat substance use disorders. California has already authorized this for Medi Cal recipients. So this is already the law for medical recipients. This is now going to extend it to private insurance. Also, on the governor's veto message, he specifically asked that we take out methadone. It has been taken out. And with that, I would respectfully ask for your aye vote.

I thank you to the author for bringing forward this Bill. I think again, it is incredibly important for us to be able to ensure that there's parity across our healthcare system in addressing this crisis that we continue to experience with that. Secretary, can you call the roll?

[Roll Call]

That Bill passes with a vote of 11 to zero. Thank you. Moving on now to item number three. AB 2132. Low's.

Thank you very much, Madam Chair and colleagues, for allowing me to present AB 2132 to help assist in tackling the issue of the growing impact of tuberculosis in our state. In fact, even in the County of Santa Clara in one calendar year, cases increased 19 percent. Members of the Legislature also passed a similar piece of legislation to tackle hepatitis and codified clinical guidelines as well. I respectfully ask for an aye vote to help tackle this issue of preventing tuberculosis and have additional witnesses here in support.

Thank you. Each witness can have three minutes, up to three minutes for their presentation.

Good afternoon, Madam Chair, Vice Chair and committee members. My name is Tanya Payyappilly. I am a physician and the CEO of Breathe California of the Bay Area, Golden Gate and Central Coast. Breathe California has been California's local lung health leader for over a century and we're working to ensure California is one of the healthiest places here to live in the country.

The agency was initially formed as a TB society in 1911 because there was no cure for TB at the time and we worked exclusively for the first 40 years to tackle TB. And we watched the antibiotic drugs come into being or developed in the 1960s and we were hoping that this would mean the end of a TB epidemic. However, sadly now, over a century later, TB still remains a major health risk.

Before the COVID-19 pandemic, TB was the number one infectious disease killer in the world and Californians continue to be disproportionately impacted. We have now an estimated 2 million Californians infected with TB and of these, 2 million, 20 percent are not aware of their disease. TB is definitely underdiagnosed and one of our core programs at Breathe California is to conduct education to the community about the risks of TB and to encourage them to get screened.

We are especially concerned in our home county of Santa Clara where there was a 19 percent increase in TB cases in just the last year. So we're lucky in California we have great TB controllers and we have agencies like us who support and do the work to educate and inform the community members about this problem. What's lacking is a requirement that screening is offered to all at-risk patients, starting with a simple questionnaire to determine that risk level.

So with our long history of community engagement, it is proven that community members will ask for or submit to screening if they know that there is an insurance coverage or if there's another funder who will cover that treatment. And AB 2132 would make this standard. There is a potential to greatly increase the number of high risk individuals who get tested with this bill and thereby the pool of TB infection will reduce whether they have a latent TB or active TB.

And our agency and others like us would go and educate them that you don't have to fear talking about it to their doctor and getting treated so that they know their diagnosis. Thank you.

Next witness. Thank you.

Good morning, Assembly Members. My name is Dr. Amy Tang. I'm a primary care physician at North East Medical Services in FQHC in the San Francisco Bay Area. So NEMS serves about 72,000 patients per year, mostly Asian ethnicity, low income and also uninsured and limited English proficient. So we care for a population that faces major health disparities in viral hepatitis B as well as tuberculosis.

In fact, in 2022, 25 percent of all the TB cases in San Francisco were among patients who received their primary care at our health center. So over the last decade or so, we've worked very closely with our public health department on trying to prevent these TB cases from occurring in the first place. And this really hinges on primary care collaborating with public health to identify those who are at risk of developing TB disease.

This requires a risk assessment and then a simple test and then a conversation with the patient about the benefits of getting preventative treatment. In recent years, NEMS has participated as a CDC site to demonstrate the effectiveness and best practices in rolling out TB preventative services. And some of the things that we've learned are if we offer a simple treatment regimen, a lot of our patients, more than half of our patients, are willing and eager to take preventative TB treatment.

But this can't happen unless we test patients and educate them on these risks. We know that treating TB disease, particularly in someone who presents to the emergency department and has to get emergency services, costs about $45,000. But if we can identify these patients up front and offer preventative treatment, it costs about $800. And so this is also something that can help save costs to the system. Additionally, about 10 percent of those who present with TB disease end up unfortunately passing away because they've been identified too late.

So this issue is a health disparity for immigrant populations and other at risk populations, communities of color in California. And we hope that you take this bill seriously. We ask that you support AB 2132 as the Assembly did a few years ago with the Hepatitis B Bill. Thank you very much.

Thank you so much. Are there any additional witnesses in support? Please state your name, organization and position only.

Good afternoon. Michelle Rubalcava on behalf of Contra Costa County in support.

Good afternoon. Josh Gaugher on behalf of the Santa Clara County Board of Supervisors in support.

Thank you. Are there any primary witnesses in opposition? Moved by Mr. Rodriguez, seconded by Dr. Arambula. No witnesses in opposition. We will move now to committee. Dr. Weber.

Thank you so much, Assembly Member Low and my fellow physicians here. I am honestly having a challenging time with this particular bill because what I see is us, as you stated from the beginning, codifying or essentially putting into law what are already clinical guidelines. So I'm going to go to my physicians who are primary care providers because I am a specialist. What are you doing right now? Like, do you not already look and do a risk assessment?

And if the patient is at higher risk, who comes to see you? Who's at higher risk coming from maybe someone who's unsheltered or someone who's immunocompromised or someone who has recently visited or lived from another country. Are you not already doing that risk assessment and then if they are at risk, offering them the test, is that not what you're doing?

I think that for North East Medical Services because this health disparity has been brought to our attention very early on with the health department and understanding that a large burden of the disease rests in our specific population, we've actually been doing a lot for TB over the last decade. But I think that our health center is a very unique case here.

If you think of a larger, very diverse population like Kaiser in Northern California, for instance, where they see maybe mostly US born patients and maybe a smaller proportion who are in that at-risk category. I don't know if I can say that a lot of other places are doing the routine risk assessment for their adult primary care preventative services and doing the testing.

We are working with Kaiser as part of the CDC grant that I mentioned and I do think that their testing rates are probably much lower than North East Medical Services, I can't really say on the record, but for us, because it's top of mind, we do probably best practices more often than some of the other institutions out there.

And so I think that for the California State Assembly to put a bill forward would really indicate that we are prioritizing addressing a health disparity that affects our immigrant populations here in this state. And I do also want to point out that since 1996, the US Preventative Services Task Force has had a recommendation to screen at-risk individuals for TB. And that recommendation was updated and renewed, I think, just last year.

But still, we haven't even come close to moving the needle on TB elimination because in the US it really hinges on identifying those who have latent TB.

Yeah, thank you for that. And I did read the updated recommendations in JAMA. That was. I actually have it right here that was updated in 2023. So is it your statement because you don't know what's going on in other facilities that those clinicians are actually not practicing the guidelines that their own colleagues recommend? Because again, I'm not a primary care physician, but I did look into the American Academy of Family Physicians and their recommendation is for their providers to follow this US Preventative Service Task Force.

So they are tasked with already doing what's in this bill. So you're thinking that they're not following their college's recommendation?

I think there's definitely under screening. I think the only hard outcomes you could look at are the number of active TB cases per year. So the assumption is that a lot of these patients who do develop TB were not screened or even if they were, maybe they weren't linked to care or offered preventative treatment. Otherwise, it's hard to really know the true number because I don't think that the TB testing is reportable for both positive and negative.

Right. And that led to another question that I had. Because there's a lot of information about our TB screen, our TB positive tests going up, right?

And in order to link it to physicians not following current clinical guidelines, do we have any kind of studies out there that show that have looked at these individuals and they say, I've tested positive now, but I just recently saw my primary care provider within the last six months, within the last year, and they just didn't do the assessment and they didn't test me. Do we have that? I couldn't find that study, but maybe that's out there.

And I just didn't see it to actually validate the need to put this in law.

I'm not familiar with large studies, but I can at least say that in 2022, when we were aware that 25 percent of the cases in SF were from our own institution, we did look at all these cases into the electronic health records to see were there several missed opportunities for these. And it's really a mix. It's a mix of situations. So for some of them, they were newer patients and there wasn't really much opportunity to have done the testing.

Some of them were very established and had been with us for decades. But there's a lot of variability in provider practice and there are others who had tested positive but had not taken TB preventative treatment. So I think the gamut of situations is really all over the place. So I can only speak for our health center, a place that actually does pay a lot of attention to this and doing a lot of provider education. But you still get those cases.

Yeah. I'm looking at this and it's already a clinical recommendation. It's already something that individual organizations tell their providers. It's kind of like, I've likened it to someone coming up here and saying that we need to do a Bill that requires OBGYNs to follow ACOG recommendations for pap smear screenings. Right. Because we still have cervical cancer cases out there. Or we do a bill that states we need to require that physicians or healthcare providers offer flu vaccines every year because our uptake is lower.

And I don't believe that we need to be necessarily putting into statue clinical guidelines that providers are already supposed to be doing. Now if they weren't doing it and if we have data that they're not, I think that's a different situation. But even to what your point is, some of the patients that were positive for TB had never even been seen by a primary care provider in your facility.

Some of them may have seen other providers that weren't necessarily primary care that wouldn't normally screen for TB anyway and wouldn't be covered in this Bill. And so when I read this Bill, I said, okay, this is important, but it's already in clinical guidelines and there's nothing that actually states that you have to do it. It's just a recommendation. And if a physician doesn't or a provider doesn't, then there's no recourse, which there shouldn't be.

So I was just kind of scratching my head to try to figure out what is the purpose and what would be a difference in the outcome. And I haven't been moved or swayed by the reading of the bill or the conversations. I really appreciate you all being here. So I personally cannot support this as is, but we'll continue to have conversations with the author. Thank you.

Any other comments from the committee?

Just to answer the question. So this bill would actually provide us a framework like I had already mentioned in our comment. I come with the CBO perspective. We go out to a lot of community members and talk to them about it. And there have been times now this is just a word for word that I can talk, but there have been cases where people are scared to talk to their doctor.

But with this required benefit, we can go and tell them that there is this required benefit, that you can talk to your doctor, get screened. And people are also worried about the payment, right?

So that's actually a big issue. So when they get to know that, okay, there's something like this, a requirement that you could go and ask your doctor, get screened and treated, and like Dr. Tang said, it is going to also save a lot of money and time for the patient and the system.

I do think it's pretty compelling to hear that there's a preventative care option of spending about $800 against the $45,000 in emergency department care that comes from being able to do this. And I also think it's compelling that we know that we have about 4200 deaths a year to TB happening, expected by 2040. So that is a significant number of the population that could be impacted by just having the ability to have additional screening as has been laid out in this legislation. Go ahead.

Sorry, chair. This doesn't change. Well, let me ask the author. Does this change coverage? Does this require coverage if it's not already there?

I can't hear.

No.

Okay. Would this open up the ability for people to be screened that are not already able to be screened?

It enhances the opportunity to be able to do so. While the guidelines are not codified, there are still close to 2 million individuals that don't know the recognition that they have TB. So there is a missing link to help ensure that we are as proactive as possible.

Right. But I guess my question is, is this somehow going to open up the doors for people to be screened that were not already able to be screened right now?

I think that's the legislative intent to help enhance that process.

How?

Hence the legislative intent.

I'm going to ask the author to just provide any additional response in your close. The motion is do pass to appropriations.

First, yeah. Author, would you like to close?

Sure. Just to remind members of the committee as well, too. This bill proposal mirrors legislative proposal last year, Assembly Bill 789, which codified clinical guidelines with respect to hepatitis B and C, which members of this committee all unanimously voted in support of as public record. And so we hope that this will increase the opportunity for access on addressing a very important issue, especially being responsive to the uptick in cases. And I respectfully ask for an aye vote.

Do you have a motion? We have a motion and a second. The motion is do pass to appropriations. With that, please, secretary, call the roll.

Bonta? Bonta aye. Waldron? Waldron aye. Aguiar-Curry? Aguiar-Curry aye. Arambula. Arambula, aye. Wendy Carrillo? Wendy Carrillo aye. Flora? Alanis? Alanis aye. Haney? Haney, aye. Jones-Sawyer? Jones-Sawyer aye. Maienschein? Maienschein aye. McCarty? Joe Patterson? Joe Patterson aye. Rodriguez? Rodriguez aye. Santiago? Schiavo? Schiavo aye. Weber? Weber no.

That bill passes with a vote of 12 to one.

Thank you. We'll move on now to Item number 1, AB 1830, Dr. Arambula. Thank you, Dr. Arambula. You may begin whenever you're ready.

Thank you, Madam Chair and Members. I will begin by thanking your Committee staff and accepting the Committee amendments. All pregnancies should be supported by culturally appropriate means. AB 1830 supports healthy pregnancies by expanding mandatory folic acid fortification to corn masa flour, masa, to prevent birth defects. Daily consumption of folic acid decreases the risk of neural tube defects such as Spina bifida and anencephaly by more than half. Babies with spina bifida can experience symptoms ranging from mild nerve damage to severe paraplegia. Anencephaly is fatal for infants.

Since neural tube defects occur in the earliest stages of fetal development, it can be too late to take folic acid supplements by the time a person knows that they are pregnant. To address high rates of neural tube defects, the FDA required that all enriched cereal grain products be fortified with folic acid beginning in 1998. While masa is a staple for many Latino cuisines, masa was omitted from the 1998 mandate.

As a result, Latinos were left without a culturally appropriate avenue for obtaining folic acid in their diets through fortification. Unfortunately, Latino communities remain at a disproportionately high risk for neural tube defects. The higher rate of neural tube defects in Latino communities is a symptom of a broader disease of health inequity. Mandatory fortification of masa through AB 1430 will right this wrong and prevent new mothers and parents from losing children to neural tube defects.

Testifying in support of AB 1830 is Ryan Spencer from the American College of Gynecology.

Thank you. You'll have three minutes.

Thank you, Madam Chair. Ryan Spencer on behalf of the American College of OB/GYNs District IX. One of our physician members, Dr. Megan Jones, was unable to make it today, so I'd like to share her experience with this issue and why ACOG is sponsoring the measure. Dr. Jones practices in the Central Coast of California. And as a maternal-fetal medicine physician, she cares for the most complicated pregnancies. The region's hospitals deliver approximately 6000 babies collectively every year, and her and her partner see approximately 100 women daily.

A majority of the patient population includes migrant workers and Spanish and Mixteco-speaking community members. Diabetes rates are elevated. Struggles with many social determinants of health are pervasive, likely contributing to the fetal abnormalities that see, such as neural tube defects or NTDs.

Implementing strategies to improve diabetes and chronic illness, which negatively impacts pregnancy, will require huge efforts over long periods of time, but there can be a focus on simple changes along the way that could be quite efficient in reducing risk in a short period of time. While corn masa flour is a cultural staple for many of their community members, money to buy prenatal vitamins, or a car to attend a prenatal visit, is a luxury.

This is where changes to fortified corn masa flour with folic acid can help provide a basic nutrient for all their mothers and children. Dr. Jones recently cared for two pregnancies with NTD or spina bifida in the last three months, and standard of care has turned toward in-utero surgery. Both of the patients declined this due to inability to secure transportation to get to the center 3 hours away. They didn't have childcare to watch their other kids at home. They didn't feel comfortable with the language barrier.

With options for improvement of their condition, these families still had an onerous task of executing. While prenatal diagnosis and management is important, prevention should be a focus. But how can a family in my community, or their community, focus on prevention when they struggle with securing basic needs? One of the leading concerns with social determinants of health is food insecurity, and this is one area that we may be able to help make a difference.

Being inexpensive and easily attributable for most, corn masa flour consumes much of the diet of many of their community members. Furthermore, folic acid fortification of corn masa flour can help decrease the risk of NTDs, cleft lip and improve prenatal nutrition. It is necessary, it is equitable, and it can be so impactful for the many families that can avoid pregnancy complications with this change. For all these reasons, ACOG is pleased to sponsor AB 1830 and asks for your aye vote. Thank you.

Moved by Majority Leader Aguiar-Curry, seconded by Ms. Waldron, Vice Chair Waldron. Thank you for the testimony. Are there any additional witnesses in support?

Thank you, Madam Chair and Members. Bryce Doherty, on behalf of the American Academy of Pediatrics, California, in strong support.

Thank you.

Afternoon, Madam Chair and Members. David Pisani, March of Dimes, in support.

Good afternoon. Josh Gauger on behalf of the County Health Executives Association of California, in support.

Thank you. Are there any witnesses in opposition? Seeing none. We'll bring it back to Committee for comment or questions.

Thank you for bringing this Bill forward. I remember years ago when my mother used to take care of some of the children that were in the farm worker housing, and two had cleft pallets. And they were always trying to figure out what it was. And then it came back to, it was probably lack of folic acid. This is a great Bill. Thank you very much for bringing it forward.

Thank you. Dr. Arambula, you may close.

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

Thanks so much. I think addressing health disparities begins before birth, and research shows that when birthing people consume enough folic acid during pregnancy, the risk of babies developing neural tube defects decreases significantly. I think this is a very smart and culturally cognizant Bill, so thank you for bringing it forward. With that, Secretary, can you call the roll?

Motion is do pass as amended to Appropriations. [Roll Call].

That Bill passes with a vote of 13-0.

We'll now move to our consent. There are no bills proposed for consent today, and so we will open the rolls for any Members who need to add on for votes. [Roll Call] I have everybody that's here. Okay. Nobody's let me know. We will hold open the roll for another five minutes if there are any Committee Members who would like to add on.

[Roll Call]