Assembly Standing Committee on Health

We'll call to order our Tuesday, April 9 Assembly on public on health on community health today we will begin as a Subcommitee. We are waiting on a Republican colleague to be able to move forward. Before we begin, I would like to make a statement on providing testimony at this hearing. We seek to protect the rights of all who participate in the legislative process so that we can have effective deliberation on the critical issues facing California. All witnesses will be testifying in person.

Please note the following we allow two main witnesses for a maximum of two minutes each instead of three minutes. 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're going to move forward. We are missing our Republican colleagues to be able to follow the protocol, although not the rule, to have a Republican Assemblymember in Committee. We don't have that. So we will move forward.

On consent today, the following bills are proposed for consent for today's hearing, any Member of the Committee may remove a bill from consent. We have seven items on consent.

Item one, AB 1915 Arambula with the motion of do pass to appropriations. Item four, AB 1996 Alanis with amendments amendments to arts, entertainment, sports and tourism. Item five, AB 2043 Boerner do pass to appropriations motion. Item eight, AB 2129 Petrie-Norris with a motion to amend with amendments to appropriations item 14, AB 2356 Wallace with a motion of do pass to appropriations item 19, AB 2549 Gallagher with a motion of do pass to human services. Item number 32, AJR 10 Erwin with a motion to be adopted.

With that, we will begin as a Subcommitee with the Member that is present to present their bill. Mister Ta, please come forward. We are on item number three, AB 1977, Ta. Assemblymember Tai go ahead.

Good afternoon. Chair and Member of the Committee. I'm here today to present Assembly Bill 1977 a modest proposal to ensure Californians with developmental disability don't face barrier to the behavioral health treatment they need. And I want to thank the Committee staff for working with my office as this bill moved through the legislative process. AB 1977 was a result of the conversation with Laurie, a mom in my district.

Laurie's son was diagnosed with autism spectrum disorder at a young age and need behavioral health treatment to manage his condition. This behavioral health treatment is life changing for Laurie's son. However, Laurie describes how, despite her son's condition being a lifelong disorder, her insurance plan would require she put her son to a reevaluation assessment once every two years to confirm his original autism spectrum disorder diagnosis. This reevaluation assessment is extensive process involving a background, questionnaire, interview and more.

Laurie's son would also have to complete additional tests every six months to maintain his coverage for his behavioral health treatment. This burdensome process would present an incredible hurdle to Laurie's family and really stressful for her son. The process would often result in delay or even denial for his necessary behavioral health treatment. All this for a condition that American Psychiatric Association describes as a lifelong disorder. Sadly, Laurie position is not an isolated incident.

Several health plans operating in California require new autism diagnosis every two years in order for patients to receive behavioral health treatment. It is required regardless a patient have previous diagnosis with them and is required prior to authorizing care. Autism service provider have report seen authorization requests delay for the children because of this lasting up to six months. Some provider have seen care delay. For a 12 and under any delay in behavioral health treatment will have an impact on the child.

Given that autism is a lifelong condition, it makes no sense to require constant rediagnosis every two to three years in order for individual to receive necessary behavioral health treatment. AB 1977 would put an end to this outdated practice and prohibit a health plan service plan from requiring an enrollee previously diagnosed with pervasive developmental disorder for autism from needing to receive new behavioral diagnosis to maintain coverage for behavioral health treatment.

We have worked with the California Medical Association to drive reasonable amendment to AB 1977 which clarified that this bill would not restrict treatment provider from reevaluating an enrollee to update their treatment plan. This should address the concerns raised by the opposition and ensure that patients can update their treatment plan if needed.

If they can condition parents will be able to to schedule re evaluation based off of their evaluation of the children autism condition instead of being fixed to an overbearing reevaluation schedule that risk jeopardizing necessary treatment. This bill is supported by the American Academy of Pediatrics California, the Council of Autism Service provider, the California State Council on Developmental Disability and others. Thank you for considering this measure and look forward to answering any questions you have. I'm honored to introduce my witnesses on this bill.

Melissa Cortese on behalf of the Gaussian of Autism Service provider and Daniel Savino from the Association of Regional Center Agency.

Thank you Melissa Cortese on behalf of Casper there we go. Thank you Melissa Cortese on behalf of CASP. CASP is a nonprofit trade Association of Autism Service provider organizations that have demonstrated, committed and are committed to promoting and delivering evidence based practices for individuals with autism. We want to thank the author for bringing this important measure forward. We did an informal survey amongst our members and we found that there are, in fact, several plans in California that are requiring this rediagnosis.

And as the Assemblymember stated, autism is a lifelong disorder. Autism is typically diagnosed by a pediatrician, a psychologist, or a neurologist. However, the generally accepted standard of care for autism is applied behavior analysis, which is provided by a board certified behavior analyst. The BCBA develops and implements the treatment plan, so when a patient is required to get a new diagnosis, they have to leave this treatment plan flow, go back to the diagnosing provider, and getting that new appointment is what's causing the delay.

And we have seen in some cases where health plans are denying authorization of existing treatment because they're waiting on a rediagnosis with autism. Any disruptions or delays can have adverse impacts. And I also want to note that existing law requires a treatment plan to include measurable goals over specific timelines and for that treatment plan to be reviewed by providers no less than every six months and modified as necessary. Thank you. Can you wrap up your comments?

It also allows the health plans access to that, and they have traditional protocols with utilization review, so there's really no clinical need for a new diagnosis. We urge your support.

Daniel Savino, Association of Regional Center agencies the Regional Centers coordinate services and supports for well over 400,000 Californians with developmental disabilities. Autism being one of the leading diagnoses within our system. It's statutory, and as the member had mentioned, there's existing scientific standards that autism is a lifelong condition. Once you're diagnosed, this is where we're at, and then we work from there. There are, as recent amendments note, cases where a re diagnosis may be necessary to more appropriately tailor treatment.

But once treatment is ongoing, it's providing a benefit. There's no need to reassess for whether or not the individual has autism. The basis of the conversation is that this is a condition that is lifelong. This type of barrier really creates a tremendous challenge for families. It's not just a simple process. Many times this is something that requires serious time, effort, and involvement.

So for families who may not have ready access to significant sick leave, transportation, the ability to coordinate childcare for other family members, they're now facing a major barrier to access and can potentially lose access to this service, at a very minimum, are going to see it delayed. We very much appreciate the member for his authorship of this and urge the Committee's support. Thank you.

Thank you. Are there any other additional witnesses and support in the room? Please come forward. State your name, organization, and your position only.

Madam Chair, Members of the Committee, Brandon Marchy, with the California Medical Association. We really appreciate the author and the Committee's work on this and appreciate the amendments. We are in support. Thank you.

Madam Chair and Members. Dylan Elliott, on behalf of the California State Association of Psychiatrists, in support. Thank you.

Good afternoon, Madam Chair and Members Tywa Rindy, on behalf of the California Psychological Association, in support. And the formal letters coming. Thank you.

Thank you. Are there any primary witnesses in opposition? I'll restate. Each witness will have up to two minutes.

Madam Chair and Members Stephanie Watkins. On behalf of the Association of California Life and Health Insurance Companies, first and foremost, I'd like to thank the Committee, the author, and the sponsors.

We've had some really productive conversations, I think, around ensuring that we understand that this is related to a re evaluation or a new diagnosis versus evaluating the treatment plan, which I think you've all heard is, is a key component to continuing to ensure that the child or the individual diagnosed with autism continues to have the right treatment.

I think we'd like to continue, if the bill moves forward today, to work collaboratively to see if we can just get some clarification that the reevaluation is related to the diagnosis and not to the treatment plan, which is just to ensure that it's consistent with current law. So for that reason, we look forward to potentially having further conversations. But today we are opposed.

Good afternoon, Chair and Members of the Committee. Robert Boykin, with the California Association of Health Plans. Regrettably, in opposition to AB 1977. We would like to thank the author's office again for getting with us in conversations on the issue and appreciate the overarching intent of the bill. However, we also like to align our comments with our colleagues at ACLHIC. As the payers in the health care delivery system, we have unique responsibility to ensure that premium dollars are being spent in the most efficient way possible.

That oftentimes includes conducting periodic reevaluations of the treatment plan to ensure our enrollees are receiving the best care possible. We are open to discussions on ways to streamline this existing process. However, we must do so in a way that will allow us to maintain our clinical and fiduciary responsibilities for our enrollees. For these reasons, we are opposed to AB 1977. Thank you for your time today.

Thank you. Are there any additional witnesses in opposition? Please come forward.

Madam Chair and Members. John Winger, on behalf of America's health insurance plans would just align our comments with CAHP and ACLHIC.

Thank you. Seeing no other witnesses in opposition, I'll bring it back to the Committee for any questions or comment. All right, we are still operating as a Subcommitee. It doesn't seem like the Committee has any comments at this time. Mister Ta, you can close.

I really appreciate the Committee staff been working with my office on this bill, and I. And I respectfully ask for your aye vote. Thank you.

Thank you, Assembly Member Ta. We'll now move to item number six, AB 2058. Weber. Apologies. Doctor Wood, are you present? Still. There you are. Thank you. You moved on me. You went from there to there. So we'll move forward with item number 24, AB 2749. Wood.

Thank you, Madam Chair. First of all, I'd like to thank the Committee and your staff for your work on this Bill. In recent years, California has made enormous strides toward both universal health care coverage and labor relations. In 2022, I authored AB 2530, which required Covered California to administer a program for workers who lose health insurance coverage during a labor dispute.

Under this program, those consumers would receive the same premium and cost sharing assistance as a consumer whose household income is at 138.1% of the federal poverty level. During the first year of AB 2530 implementation, it was discovered that clarification is needed in the language. Labor disputes, particularly in large industries, can be complex and affect surrounding employers and workers. This proposal clarifies eligibility for the program to reach the intended target of workers and employers who are directly involved in the strike.

It also provides additional clarifications and changes to the law that will better enable Covered California to implement the program and ensure the benefits of this important program are administered effectively to workers who need them. AB 2749 is being amended to address concerns raised by labor. Here to testify and support is Sara Flocks, representing a coalition of labor organizations, including the California Labor Federation. And here to answer any technical questions is Kelly Green, Director of communications and external affairs for Covered California.

Madam Chair Members, Sara Flocks, California Labor Federation and we wanted to thank the author for taking amendments so that we could fully support the Bill today in Committee. And I'd like to say that it is rare for me that I get to see a Bill signed into law and then so effectively implemented and used by workers. After this Bill passed, we went into a strike wave.

There was the entertainment union strikes, but there were also strikes that did not get a lot of publicity, including a strike by transportation workers, private sector transportation workers in Visalia. This was before Covered California was ready to implement the program. Yet workers were losing coverage, and a lot of these were couples that worked for the same company, and so they were completely losing coverage.

Covered California sprang into action, had people that were available to seamlessly get workers enrolled onto coverage so there was no gap and the program was effective. It was really an example of a law working on the ground and making a difference in workers lives. These changes are things that we learned during the process that hopefully will make it work even better. So we urge your aye vote.

Thank you. Go ahead. Thank you.

Madam Chair Members Kelly Green with Covered California, joined by Allyson Pease, our assistant General counsel here if there are any questions. Thank you.

Are there any other witnesses in support? Please come forward. State your name, organization and position only.

Good afternoon. Member chairs Beth Malinowski with SEIU California in support.

Beth Capell for Teamsters and Unite Here also in support as amended. Thank you.

Thank you. Are there any witnesses in opposition? Plan to testify? I'm not seeing any witnesses in opposition as me toos. I'll bring it back to the Committee then. Committee Members, any question? Comment? No, miss. Doctor Wood, you mean close?

Just when you have a quorum and respectfully request and aye vote. Thank you.

Thank you so much. I know that you know exactly what it feels like to be.

I do. I feel your pain.

Chair Emeritus, Doctor Wood will be moving forward with item number 29, AB 3129.

Thank you. Thank you, Madam Chair. I'd like to start by thanking Committee staff for their work on this Bill. I will be accepting the amendments. There is no question that trends in private equity ownership have rapidly increased across almost all all healthcare settings. A study published in July of 2023 evaluating this trend drew from a database of 1778 studies, with 55 being empirical research studies that evaluated private equity owned healthcare operations.

Across the outcome measures, private equity ownership was most consistently associated with increased cost to patients or payers, and mixed to harmful impacts on quality. Out of four impacts, health outcomes, cost to patients or payers, cost to operator and quality, 25 were determined to have harmful outcomes, nine were mixed and eight had beneficial outcomes. I don't know about you, but I'm interested in our state protecting patients before they pay more for less care or lesser quality of care, no matter what the statistics.

That's why I'm here to present AB 3129, along with our sponsor, Attorney General Rob Bonta. Colleagues, I hope you know of my work the past nine and a half years. It's all about protecting patients and controlling healthcare costs. That's why I've been focused on this trend for the past several years.

As a health care provider, I hold dear state law barring the corporate practice of medicine, ensuring that providers can practice independent of another entity, telling them how to practice this Bill reinforces that we all know what private equity's first interest is, making a profit. They wouldn't risk it if they didn't. We also know that timelines are short, often three to seven years.

And we know that in order for them to make a profit, they look to lower costs for the entities as well as increase leverage, making them more attractive to future buyers. Is making something more efficient bad? No, but it can be harmful. By reducing staffing and limiting resources, consolidation can also increase leverage, allowing them to negotiate higher fees, increasing the cost of healthcare, and possibly restricting access to certain services like reproductive health care.

We are aware that private equity has provided funding for expanding services, but we are also aware of private equity taking such a hold on an area that there is no longer competition and that monopoly can result in negotiations of higher fees because there is no other option. This Bill does not prevent these acquisitions. It does allow the Attorney General to review them to ensure they are in the best interest of patients. As I always do, I carefully listen to opposition's concern.

But there is a basic question here. Given the results shown by many studies, not just one, that there are harmful outcomes, then how can the opposition argue that these transactions should be getting an automatic rubber stamp without any review? This trend continues to grow exponentially and our goal should be looking at the investments and how they are affecting patients and the cost to healthcare. If not us, then who?

Today to testify for the attorney is Deputy Attorney General Tiffany Matthews in the Attorney General's Office and Katie Van Dynes, Policy and Legislative Advocate for Health Access California, Special Assistant James Thoma from the Attorney General's Office is also available for questions.

Thank you. You can proceed with two minutes time.

Good afternoon. Chair and Committee Members Tiffany Matthews, Deputy Attorney General and legislative advocate at the California Department of Justice. I'm here today on behalf of Attorney General Rob Bonta, who is a proud sponsor of AB 3129 and he thanks the leadership of Assemblymember Wood on addressing consolidation in our healthcare system.

AB 3129 authorizes the Attorney General to review healthcare transactions involving private equity and hedge funds, and it also reinforces the existing bar on the corporate practice of medicine as it applies to the interference of private equity groups or hedge funds in the medical care of patients. The Bill focuses on private equity for two main reasons.

The first reason is that the private equity business model, which is designed to buy an asset, maximize profits and then sell that asset, has concerning effects when applied to our healthcare system. We are seeing healthcare facilities and provider groups being bought up by private equity. Cuts to staff and services are being made to increase profits and then that facility or provide a group is sold, oftentimes susceptible to bankruptcy, further consolidation or shutting down, jeopardizing the surrounding communities access to healthcare.

And the second main reason is the alarming pace at which these private equity acquisitions are happening. They have doubled in the past decade. AB 3129 would set up oversight over these transactions where the Attorney General would have the authority to approve, deny, or approve with conditions these transactions based on whether they are in the public interest. This review process is not an automatic denial of these transactions. The oversight is to help ensure that Californians have access to affordable health care.

And for these reasons, we respectfully request an Aye vote.

Thank you. Go ahead.

Good afternoon, Madam Chair and Members. I'm Katie Van Deynze with Health Access California, the statewide healthcare consumer advocacy coalition. And we are here in proud support of AB 3129 by Assemblymember Wood. For more than 30 years, Attorney General's of both parties have had the authority to approve, deny, or approve with conditions mergers related to nonprofit healthcare transactions. In the last 30 years, between 80 and 90% of those nonprofit hospital mergers have been approved, mostly with conditions to protect consumers.

What kind of conditions have AGs asked for? To keep emergency rooms open, to keep labor and delivery rooms open, to keep cardiac care and other services open, to not hike up prices for consumers and to not end managed care contracts for consumers for MediCal, and to not close hospitals. These are the exact kind of conditions that communities need and that we hope to see moving forward to protect access to affordable health care in communities. This process is not new.

What is new is that private equity is taking over hospitals, skilled nursing facilities, and doctors groups and research has shown that this drives up prices for healthcare, can have dangerous impacts for quality as well as risks for access to care in communities. AB 3129 was subject private equity to the same kind of oversight and public scrutiny that nonprofit hospitals have had for decades. When there is a merger and acquisition in healthcare, we often hear about wonderful things that will happen, like innovation and efficiency.

We want to have the Attorney General to have the oversight authority to hold private equity accountable to these promises and prevent negative impacts for our communities.

Thank you. And I respectfully ask for your Aye vote on this Bill.

Thank you. Are there any other witnesses in support? Please state name organization position

Madam Chair and Members, Tim Madden, representing the California chapter at the American College of Emergency Physicians in Support.

Good afternoon again. Beth Malnowski, the SCO California and strong support also registering support for NextGen California.

Good afternoon, Madam Chair Members. Mari Lopez with the California Nurses Association in support.

Dylan Elliott on behalf of the California State Association of Psychiatrists in Support. Thank you.

Erin Evans, on behalf of formerly NARAL Prochoice California, currently reproductive freedom for all and support. Thank you.

Seth Bramble, speaking on behalf of the California Teachers Association, we are in support.

Good afternoon, chair Members Janice O'Malley with AFSCME California here in support.

Madam Chair Members Brandon Marchy with the California Medical Association, support the Bill in concept, appreciate the conversations that we've had with the sponsor and the author thus far, and look forward to continuing our work. Thank you.

Good afternoon. Chair Peter Sidhu, UNAC/UHCP Executive Vice President and support for the Bill. Thank you.

Are there any primary witnesses in opposition? Thanks so much. You'll each have two minutes.

Good afternoon, Madam Chair, Members of the Committee, Dr. Wood, this is an issue that has been around for some time and Dr. Wood and I have agreed to disagree. Let me offer that I'm here on behalf of the American Investment Council and we view AB 3129 to propose a significant expansion of the AG's powers over health care transactions to include unprecedented oversight over changes of the control of governance of healthcare facilities involving private investors. Further, these new requirements would apply to a broad range of investors.

While the proposed bill uses terminology focusing on private equity and hedge fund. In fact, the bill applies in a far broader capacity. It would impact any investor in the healthcare space. Further, AB 3129 seeks to cut off critical source of funding for healthcare and we also find that while Dr. Wood has presented both in his fact sheet and his testimony studies that support the proposition in the bill, there are also an equal amount of studies that contradict that.

I would point out to the one finding in the study that he presented which states more study is needed to understand the impact of PE acquisitions on healthcare. More studies, starting with the development of better data sets, is needed to understand the complex impact of PE ownership in physician practice and healthcare markets. Finally, we all know about the enactment of Senate Bill 184, which created the Office of Healthcare Affordability.

In presenting this bill, I quote, the proponent said that OHCA will collect and analyze the health care market for cost drivers and trends in order to develop data informed policies and enforceable cost targets with the goals of containing healthcare costs and providing quality and affordable health care to all Californians. We would simply ask that you reject this bill and let OHCA do its job.

Please go ahead.

Thank you. Good afternoon, chair Members of the Committee, Rony Berdugo here on behalf of the California Hospital Association, respectfully in opposition to AB 3129. We believe patients deserve access to effective, reliable healthcare services and these services do depend on constant innovation and investment. Here in Sacramento, for example, patients have been the beneficiaries of a new rehabilitation hospital resulting from a partnership between UC Davis and private investment.

As drafted, AB 3129 is, at a minimum, unclear about when the Department of Justice will step in to review transactions, giving it broad authority to approve, reject or impose conditions which can slow or eliminate much needed investment in health care. The bill's definition of change of control is also unclear, including indirect control and sharing of control, where there are even minor changes in a hospital's governance.

The DOJ's existing authority over nonprofit hospital transactions has already served as a barrier for investment in healthcare and was one of the contributing factors that led to the closure of Madera Community Hospital. Access to all financial tools is critical, particularly in vulnerable communities where investments are needed. It's important to note California will be reviewing these very transactions through the Office of Healthcare Affordability. That law prohibits transactions from closing until 60 days after OHCA publishes its final impact analysis.

Plenty of time for the DOJ to exercise its current authority to investigate anticompetitive behavior. Furthermore, California has numerous policies implemented by hospitals that are designed to protect patients regardless of their ownership. At least five different departments and agencies conduct extensive oversight at all points of patient care. These policies align with the hospital's core mission of caring for its patients and workers. Unfortunately, while AB 3129 may be well intentioned, we think it raises more questions than answers, putting at risk, innovation and additional investment in patient care. For these reasons, we respectfully ask for your no vote. Thank you.

Thank you. Are there any other witnesses in opposition, please come forward.

Good afternoon, Chair and Members, Kim Stone of Stone advocacy, on behalf of the California Orthopedic Association, in a respectful, opposed unless amended position.

Thank you. Preston Young from the California Chamber of Commerce here today. In opposition.

Meghan Loper, on behalf of the United Hospital Association, in opposition.

Good afternoon, Madam Chair and Members. Connie Delgado, on behalf of Newport Healthcare, with concerns for many of the reasons that my colleagues mentioned.

Thank you. Seeing no other witnesses in opposition, I'll bring it back to the Committee for a comment or question. Dr. Weber.

Good afternoon. Thank you so much for introducing this bill and allowing us to continue the discussion of how we should be providing healthcare and access to our residents in California.

You know, I agree with what was stated before. Definitely agree with the concept. Definitely want to thank you for the inclusion of the non complete clause, because that is a huge issue for us providers. Just have a couple of questions that either you or the AG's office could answer for me. So you break down different ways for non provider versus provider versus provider group. So what was the purpose in those different definitions for each of those categories or the thought process behind it?

I think it's pretty difficult to lump everybody all together in a single category. So we do. We look at payers and break down how we consider payers. We look at provider being defined as two through nine healthcare providers, and then a provider group being larger than that. I think that there are distinctive differences between those three categories of people. And so, you know, this part of that is we're still.

That may still be a little bit of a work in progress, but it is a recognition that there are differences based on the size of the group and the payer component as well. I'll let the AG's office, if they have any comment.

No, that is correct. Dr. Wood is right that the private equity have been particularly active in provider groups. And so we are trying to focus those provisions to hit the differences between different groups. You can see that this bill affects healthcare facilities because that is also where private equity was inactive in terms of hospitals and so forth.

And with physician groups and provider groups, we wanted to make that clear that this would apply there, because that's been another source of problems in terms of the provision of healthcare access. Those definitions are technical, and so they are, as Dr. Wood mentioned, still under review to make sure that we have this right. But that was the idea of trying to find the right mix and the right balance for which groups would be impacted by the bill.

Yeah, no, I just found it a little unusual that, like, non providers include this amount versus providers that include, you know, this amount. I would think there would be a little bit more uniformity.

I think the reason behind, part of the reason behind that is that what we are seeing in the acquisition space is that private equity is tending to gobble up, so to speak, more smaller groups. And when you can get to a point where you now have market superiority, where you have essentially eliminated competition by gobbling up a lot of variety of groups, they're going to come in different shapes and sizes. And so we want to be sure we capture that.

And that when the Attorney General is looking at these mergers, that they are aware that a particular group has now owns a whole bunch of components, other smaller groups there, that now makes them a bigger player. And that is the challenge. When we look at competition in the market.

We saw, we saw, look, all this work starts from back with Sutter health years ago, and we saw what happened in Northern California, where we now pay more for healthcare in Northern California than in Southern California, because Sutter systematically was able to corner the market. And when you are the only, are you the dominant force in the market and there's no competition, that's huge leverage with payers particularly, and employers who need to have coverage for their, for their employees.

Yeah. Thank you for that clarification. When you, in the bill, when you talk about the revenue threshold, is that based on gross or net revenue?

It's gross revenue.

Gross revenue. Okay. And then for this particular bill, looking at the revenue threshold as a metric, but in previous bills, you've kind of looked at, like, practice size or transaction value. What was the rationale for the difference? Is it that this is how these private equity groups move, or what was the rationale for the difference?

You know, I think if you look at earlier bills, we were, it was as low as $5 million. It may have been a bill that even said $1.0 million. I can't remember, I can't remember that far back, quite frankly.

But, you know, if you're looking at a group of, you know, handful of providers that could easily be, you know, seven to nine providers, that could be a $10 million threshold or less moving there, I think the point is to not, we're trying to get our arms around the totality of what's happening in the marketplace. And so that's where we're trying to find that particular sweet spot. I'll say this for the opposition, because they probably will if they're asked.

People want this to be like $101 million, which, which is the federal threshold. And I'm sorry, that would be wholly inappropriate. It would never capture what we're trying to do here. But we think at this point, until we can be compelled to see it another way with data, that $10 million is an appropriate threshold.

Thank you. And then we'd love for you to, to comment on what the opposition talked about when they are referring to the office of Healthcare affordability and, you know, the difference and how this is one of the areas in which the Office of Healthcare Affordability is supposed to be kind of overseeing. Just give you the opportunity to respond. Thank you.

Appreciate that. I worked on the Office of Healthcare Affordability, as did every member of the Health Committee staff, for a long time. And this was one of the thorny issues, quite frankly, consolidation in the marketplace. We always knew we were going to go back and have to look at this particular issue. As a matter of fact, I introduced a bill last year to look at this particular issue.

What's different about this bill is it is very tailored to the private equity venture capital market, which is an emerging challenge nationwide. And my concern is that OHCA wasn't specifically tasked in this arena. And I want to give them the tool to be able to look more closely at this before it's too late, before we have another Sutter situation that affects healthcare throughout the state and drives costs higher for patients.

I want to thank the author for bringing this forward. I know that this has been really an opportunity for you to take your many years of service as chair of the Health Committee to really look at some of the, as you said, some of the emergent trends that we need to be, quite frankly, very concerned about as we think about the corporatization of. Of our health care system. So I'm very thankful to you for bringing this forward.

I believe that it is well situated to ensure that the Department of Justice has the ability to remark on these kinds of acquisitions, given their prior experience doing so in the nonprofit context. And with that, we still do not have a Committee on the whole. So, Author, you have any closing comments, please?

I want to thank the chair and the Committee for questions and appreciate. This is a challenging, complicated subject. I don't approach it lightly. I will continue to work with opposition. Although I think Mister Prea is correct. We may agree to disagree on some of these issues. I am concerned about the emerging trends. This isn't just physicians groups. This is skilled nursing facilities. Laboratories, potentially. But the biggest consolidation we're seeing right now nationwide is in skilled nursing facilities.

And what we're seeing is in some of those facilities. One of the first things that's happened is to cut costs, is to reduce staffing levels to taking care of some of our most vulnerable people by reducing the care that's provided to people. And I'm not saying that all consolidation is bad. I'm not. But I do want to be sure that patients don't have to bear the cost of consolidation simply for profit. And that's really what this is about.

Private equity firms, venture capital firms, are all about profit. I would point you towards an article in Sunday's New York Times about a company called Multiplan. Multiplan. And it's complicated, and I don't want to take too much of the Committee's time. Here is a venture capital funded company that acts as an intermediary with insurance companies to reduce reimbursements to hospitals and shift costs to patients for a fee. They are fee generated, much like pbms are. And this is all about profit.

This is all about profit and maximizing and shifting costs. That article should raise the hair on the back of your neck. And I urge you to read that. It was in Sunday's New York Times. Thank you. With that, I respectfully request, and I vote when you have a quorum.

Thank you, Dr. Wood. We are going to move forward with your next Bill, which is Item number 31, AB 3218.

Thank you very much. I appreciate. I'd first like to thank the Committee and their staff for their efforts on this measure. State law prohibits flavored tobacco products in California, but unfortunately, they remain readily available throughout the state. The high rate of flavored tobacco use among youth is especially concerning. A 2023 study by the CDC indicates that among middle and high school students who use tobacco, nearly 90% use flavored products.

AB 3218 creates a pathway to ensuring flavored tobacco products are no longer available on the shelves of retailers and in our communities by creating an affirmative listing of unflavored tobacco products that are legal in California. This approach will help retailers determine at a glance whether the product delivered to the stores is legal or not. Additionally, the Bill authorizes the Attorney General to penalize distributors that sell illegal tobacco products and manufacturers that falsely certify their products are unflavored.

And finally, the Bill also authorizes law enforcement to seize illegal tobacco products from distributors. These comprehensive enforcement steps will help implement the flavored tobacco ban by the way it was intended. Here to testify in support is Tiffany Matthews with the Attorney General's Office, the sponsor of the Bill, and Agamroop Kaur with the Campaign for Tobacco-Free Kids. Special Assistant to Attorney General James Toma is available to answer any technical questions.

Thank you. Please go ahead.

Good afternoon, Chair and Members. Tiffany Matthews, Deputy Attorney General and Legislative Advocate for the California Department of Justice, and here today on behalf of Attorney General Rob Bonta. So the Attorney General is a proud sponsor of AB 3218, along with our co-sponsors campaign for Tobacco-Free Kids, the American Lung Association, the American Cancer Society, and the American Heart Association.

Attorney General Bonta would like to thank the author, Assembly Member Jim Wood, and the principal co-author, Assembly Speaker Robert Rivas, for carrying this important piece of legislation that will ensure the successful implementation of the flavored tobacco band. When the ban went into effect, our office received a number of inquiries asking for guidance and assistance in effectuating the rollout of the law.

Our office drafted AB 3218 in response to these inquiries, and as a next step in accomplishing the ban's policy goals of getting these flavored tobacco products out of the hands of our youth. AB 3218 would do five main things. First is that it would establish a publicly available list of all tobacco products that are permissibly unflavored and allowed to be sold in California.

The second thing is that it would render illegal, flavored products ineligible for tax stamps so that such products can quickly be removed from commerce and never reach our kids. The third thing is that it would hold the distribution chain accountable at a higher level. The fourth is it would clarify the definition of characterizing flavor to specifically prohibit products that impart menthol-like cooling sensations.

And the fifth and last is that it would authorize the Attorney General to omit from the unflavored list any tobacco products lacking the required FDA authorization. In sum, AB 3218 would hold sellers of illegal tobacco products accountable and reduce access to flavored tobacco products, particularly among youth who gravitate towards these products and help prevent them from entering a lifetime of addiction. Thank you for your time today, and I respectfully ask for your aye vote.

Please go ahead.

Thank you, Madam Chair and Committee Members. My name is Agamroop Kaur. I'm representing the Campaign for Tobacco-Free Kids as a youth member of the board. I'm here today to continue the advocacy we began with SB 793 and the referendum in 2022, and to really fulfill the mission I set out on as a middle schooler to ensure healthier futures for my siblings, our communities, and youth all across California.

On behalf of the sponsors of the flavored tobacco law, I wanted to personally thank Attorney General Rob Bonta and Dr. Wood for their diligent work on this issue. The tobacco industry has made passing this Bill necessary, as while they lost their fight to keep kid-friendly flavors on the shelves here in the Legislature in 2020, and then again at the ballot in 2022, that hasn't stopped them.

Menthol-like cigarettes were invented to replicate the taste and sensation provided by menthol cigarettes in order to keep up the relentless targeting of youth in our communities of color. This Bill will help clarify what is a flavored tobacco product and what isn't with a list, and update the characterizing flavor definition to include a numbing or cooling sensation. The unflavored tobacco product list starts with a position that the onus should be on the tobacco industry to show their products aren't flavored.

The stakes for passing this Bill are really shown in the data from the CDC Foundation, stating that while sales of flavored e-cigarettes have declined by 70% since SB 793 went into effect, over one third of e-cigarette sales in California are still for illegal flavored e-cigarettes. As a result, these products are still getting into the hands of California's kids, which is why we need you to protect our communities and urge an aye vote on this critical legislation. Thank you.

Thank you. Are there any other witnesses in support in the room?

Kelly Brooks, on behalf of the County Health Executives Association of California and the Santa Clara County Board of Supervisors, here in strong support.

Brandon Marchy with the California Medical Association in support.

Dylan Elliott, on behalf of the American Heart Association, proud co-sponsor and in support. Thank you.

Jessica Moran with the California Dental Association in support.

Autumn Ogden-Smith with the American Cancer Society Cancer Action Network, also in support.

Isa Verse with the American Lung Association in support.

Thank you. Are there any primary witnesses in opposition? Thank you. You'll have two minutes.

Thanks, Chair. John Winger, on behalf of the California Fuels and Convenience Alliance, representing the majority of gas stations and convenience stores in the state. First, I'd like to thank the author and the sponsors for the continued dialogue on the Bill. Apologies for not getting our letter in on time. We were reviewing the amendments last week and wanted to spend some time on that. So we do currently have an opposed unless amended position on the Bill.

I think in concept, a tobacco directory would be very helpful and some statewide guidance would be very helpful. We've seen a pretty large patchwork of enforcement on the local level which has been difficult for our station owners to comply with. We do still have some remaining concerns just over the broad discretion that the AG is given in the Bill.

We also have some concerns around the perjury, the penalty of perjury language and how that would kind of jive with the FDA backlog on approval of products, and then finally have some existing or some ongoing issues with the definition of characterizing flavors. And so we'd like to continue those discussions. I think from our perspective, if the language is overly broad and captures more additional products that could bolster the illicit market further, which continues to be a problem that we see.

And so we'd like to continue those discussions. But as of today, we do have an opposed unless amended position. Thank you.

Thank you. Are there any other witnesses in opposition? Please come forward.

Dennis Loper, on behalf of the California Distributors Association, we have some concerns and would like to align our comments with the convenience stores.

Thank you.

Madam Chair and Committee Members, Tobias Wolken with the California Taxpayers Association. We were unable to take a position on this Bill before the hearing, but our organization regularly monitors state tax collections of tobacco tax revenues. We believe that the growing underground economy's effect on tax collections is significant and needs to be addressed. And while I can't officially provide a position for CalTax today, we do believe increased enforcement of existing laws is important. Thank you.

Thank you. I'll bring it back to the Committee for any questions or comments. Dr. Wood, I would like you to address the query from the opposition around the naming of the flavors and what the impact of that would be and why that's an important part of the legislation.

Thank you, Madam Chair. And it's a critical piece of the legislation. Right now, it's difficult for convenience store owners, retailers to know what's legal and not legal. My instinct is that they rely on their distributors, as is not unusual in many businesses, to provide them with products that are legal. However, I think a list of what is legal and approved, that is by the FDA, I think is an important component here, and that's what we're striving to do.

I can't help that the industry might feel that there are some products that might be compliant, but haven't worked through the FDA process. When they do ultimately work through the FDA process, they will be added to the list of eligible products to be sold in California. We don't have control over what the Federal Government does in this arena, but we do know that there are a lot of counterfeit products and things that show up on the market out there that are.

And part of this is looking at how things are labeled and keeping people accountable. It's not my desire to bankrupt mom and pop stores and anything like that. We've heard this argument over and over and over again from the tobacco industry. But there are so many other profit centers and small convenience stores that I struggle to see how this is going. With the decreasing number of smokers and tobacco users in California, I struggle to see how this is going to be a major component in the demise of businesses, which is often what we hear.

I think more powerful is the fact that you have somebody who started this work with you when they were in middle school. So I just want to commend the witness for being such an advocate for all of our health, particularly our youth, and bringing that voice into the room. Appreciate that.

And I think finally, through the Chair, if you don't mind. I think one of the most important things is here, this is about protecting the youth of the state from beginning down a path to tobacco use. And it happens through the use of flavored tobacco products, because the flavorings make it more palatable. Menthol and other kinds of flavors make it more palatable. And then once you're addicted, you are addicted, and it is the hardest thing to kick. So this is really about protecting youth.

And this is a good example. I think, just like the first Bill I presented, things are not always perfect out of the gate. And now we're seeing the opportunity to go back and refine and make sure that this Bill is actually doing what SB 793 did to help supplement that, just as with the labor Bill on striking workers in their health care.

Can we take that as your close, Doctor?

Yes, absolutely. Thank you.

Thank you. Thank you for presenting the Bill. We are still without a quorum, so we'll move on to our next item. Next item will be item number 12. AB 2258 Zbur Mister Zbur, feel free. And if there are any witnesses in primary opposition, please make your way forward to go ahead, your mic's not on.

Madam Chair, thank you very much. I also want to thank Assembly Member Jackson for letting me jump ahead of him in line, so thank you. Today I'm proud to present AB 2258 which is sponsored by Insurance Commissioner Ricardo Lara, Equality California, APLA Health, Los Angeles LGBTQ Center and San Francisco AIDS Foundation. A study found that a $10 cost for HIV prevention medication doubled prescription abandonment rates, increasing the potential for HIV infection in those patients.

Barriers to preventative care force people to choose between preventing expensive and devastating health problems before they occur, and putting food on the table. While we do have protections for preventive care in California, some of them are based on federal protections. And there's concern that recent court cases may put the federal preventive services requirements, which our state relies on, into peril.

That's why AB 2258 is so important, as it will codify in California existing federal guidance requiring health plans and health insurers to cover services that are integral to delivery of recommended preventive services without out of pocket cost, including reversible contraceptives, PrEP HIV, and HIV and other STI screenings. In essence, this Bill is about ensuring that low income people have access to the same comprehensive and affordable preventive health care as anyone else.

With me today is Sebastian Perez, representing APLA Health, and Stasha Hodges with the California Department of Insurance, sponsors of the Bill to provide additional information and assist with questions.

Thank you. You'll have two minutes each.

Honorable Chair Bonta and Members of the Assembly Health Committee. My name is Sebastian Perez and I am the state affairs specialist at APLA Health, co-sponsor of AB 2258. APLA Health is an FQHC that provides HIV and STI testing, treatment and preventive care to the LGBTQ and underserved communities of Los Angeles County. So, to curb the spread of HIV and STI's, we offer Low and no cost PrEP, PEP and STI screening and treatment services as successfully as possible.

Excuse me, so many of our Low income patients initially believe that PrEP is too expensive for them, but our services inform them that PrEP, medication, HIV testing and STI screening are actually available cost free to many Californians. And cost sharing is a barrier to care. Preventing share of cost on PrEP related integral services like quarterly provider visits and lab tests removes those barriers.

PrEP and PEP are clinically proven to stop the spread of HIV over 99% of the time, but uptake is still disproportionately low among patients at elevated risk for HIV, namely gay and bi, black and Latinx men, and transgender women of color. The Affordable Care Act provisions require health plans to cover certain preventive services with no cost sharing. But this mandate has been challenged recently in Texas.

In the Braidwood decision, a judge ruled in favor of a company that refused to include PrEP coverage in its health plan on religious grounds because PrEP, and I quote, promotes homosexuality. The plaintiffs also challenged the constitutionality of the body of experts who established preventive care guidelines in the ACA. If Braidwood reaches the US Supreme Court, the court could uphold Braidwood making the preventive care mandate unenforceable and, crucially, leaving our patients and many others seeking preventive care at risk.

AB 2258 would codify the guidelines on cost free preventive care for all Californians. Sorry for all California regulated health plans and their patients. I urge you to vote aye on AB 2258. Thank you for your time.

Good afternoon, Madam Chair and Members of the Committee. I am Stasha Hodges. I'm an assistant chief counsel in chief of the Health Equity and Access Office for the California Department of Insurance. I am here today on behalf of Insurance Commissioner Ricardo Lara. First, I want to thank Assembly Members of Burr for Authoring AB 2258. The Department of Insurance is a proud cosponsor of this Bill.

Existing law requires coverage of the same preventative services as found in the ACA without cost sharing, but state law does not incorporate the associated federal clarifying guidance. AB 2258 codifies existing federal guidance providing that integral healthcare services, which are necessary to provide a recommended preventative care benefit, must also be covered without cost sharing. I want to stress that this requirement to cover integral services without cost sharing is currently required under federal law.

Codifying the integral services requirement in state law is particularly urgent in the wake of the Braidwood versus Becerra decision that came out of Texas last year, which struck down preventive care requirements under the United States Preventative Services Task Force. If that decision is ultimately upheld by the courts, then the federal guidance on integral services will be unenforceable.

Enacting AB 2258 is one way the state can ensure that should the Braidwood decision ultimately be upheld, California's consumers are still afforded the full protections of integral services that were in place before that decision. And for these reasons, Insurance Commissioner Ricardo Lara and the Department of Insurance urge your aye vote on our co sponsored Bill, AB 2258.

Thank you. Any other witnesses and support?

Thank you, Madam Chair Members Doug Subers on behalf of the Los Angeles LGBT center, pleased to be a co sponsor and a strong support.

Chair and Members. Erin Evans, on behalf of Reproductive Freedom For All in support. Thank you.

David Gonzalez, on behalf of the California Life Sciences and support. Thank you.

Greg Pulsifer, on behalf of Equality California, co sponsor, in support.

Molly Robeson, Planned Parenthood affiliates of California, in support.

Mari Lopez, California Nurses Association, in support.

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

Ryan Souza, on behalf of the San Francisco AIDS foundation, co sponsor and proud support. Thank you,

Madam Chair Members. Rand Martin here, on behalf of the AIDS Healthcare Foundation, in strong support of this very important Bill. Thank you.

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

Magali Zagal registering support on behalf of ECLU

Alex Kahn with the California Chronic Care Coalition in support.

Oh, my mic is. No, I just wanted to say that, is there any. How did that lawsuit or issue in Texas get brought to Lightwood Management? I mean, what caused them to look at it?

Any witnesses in opposition? Seeing none. I'll bring it back to the Committee for a comment or question. Vice Chair, go ahead.

I mean, I think they are concerned about the coverage of the very things that we want covered, the printed services for PrEP, a lot of these kinds of coverages. And essentially what the Bill does, we rely on that federal guidance to make sure that our consumers in California have coverage of PrEP and all these affiliated services.

And so this is sort of a precautionary Bill because of the lawsuit, if it goes the wrong way, we want to make sure that we actually codify the existing federal guidance in California law so that those protections continue for California consumers.

Yeah, a couple years ago, I had a Bill that got signed, thankfully, that added to the training for physicians that they could be more knowledgeable about PrEP and PEP and other things, because we found that less than 30% of physicians were even familiar with it. You know, I agree that the screenings and preventative care are critical, not only because of early diagnosis, treatment for the patient, quality of life, but also it's a great way to reduce costs in the end.

So thank you for bringing this Bill forward.

Thank you.

Thank you. Seeing that Mister Zbur may close, chair.

And Members, thank you very much. I respectfully ask for an aye vote.

When the time comes. Thank you so much, Mister Zbur. We'll move forward now with Doctor Jackson, who is patiently waiting. Item number two, AB 1970.

Please proceed.

Thank you very much, Madam Chair. Don't worry, I'll be cashing in on that. On that line cheating of Mister Zbur. Absolutely. You know I'm going to cash in that favor. Thank you very much, Madam Chair. This bill aims to address the existing disparities in mental health care access services within California's African American communities.

It will require the Department of Healthcare access and information to establish guidelines for a specialized certificate program tailored to mental health navigators who seek to serve the African American community within the existing Community Health worker certificate program. Additionally, the bill mandates the development of specific training requirements for their certification and reporting requirements. This bill offers a solution by providing specialized training, certification and a clear pathway for African American individuals in California to access proper mental health treatment and services.

This bill also ensures the collection and reporting of data on certified individuals and those actively engaged in community health worker positions, enabling accountability and tracking progress in addressing mental health disparities. And I'll now turn it over to my witness.

Go ahead. You'll have two minutes. Thank you.

I'm Traci Stafford and I'm the chair of the California Black Health Policy Advisory Council, and this is a group that has come together to advance Black health. Equity, uniting communities and elected leaders to to recommend, champion and monitor policies targeting black health inequities in the State of California. Over the last 18 months, we have gathered with over 13 statewide organizations focused.

In this area and dozens of individuals who are psychologists, psychiatrists, healthcare workers, labor unions, community members, black health organizers and advocates.

And with all of the challenges that are faced with black health inequities. What came to the forefront in the very top, every single meeting that we had was mental health services, and participants shared personal and client heart wrenching stories of trauma, reluctance to seek help, the weight of unspoken traumas, which we call. Weathering, and the struggles of navigating a mental health system that fails to provide.

Culturally competent care, leading to misdiagnosis of paranoia and other afflictions, rather than the very real racial trauma that is often in play. Participants spoke of the crushing weight of systemic racism, bias and socioeconomic inequities leading to profound stress and anxiety in black communities. They mourn the devastating consequences, including broken families, poverty, homelessness, and suicide, when mental illness and racial trauma and chronic racial stress are left untreated.

And this cycle continues with each generation. In addition to the everyday challenges that we all face, most black Americans, according to Harvard Business Review and many other organizations, that most black Americans, regardless of education, socioeconomic status or job title, experience one or more forms of bias every single day. Underscoring the need for culturally competent resources.

To that end, participants overwhelmingly noted the lack of black therapists, citing the disconnect that arises when cultural understanding is missing from therapeutic relationships. As mentioned, or will be mentioned, only 2% of psychiatrists and 4% of psychologists in the United States are black. And that number, when we talk about culturally competent mental health professionals in terms of the black experience, is anticipated to be a mere fraction of that.

Thank you. Can you wrap up your comments?

Well, thank you. That's the close.

Well, what I'll say in close is. That not only is this a mental health, have mental health support, but it is also most definitely a workforce development bill that will help create jobs for people who maybe cannot afford to be in the mental health and mental health careers, but this provides a way into that. So we just ask that you consider approving this bill.

Thank you, Miss Stafford. Are there any other witnesses in the room in support. With that if there are any primary witnesses in opposition, please come forward to the table.

Kat Bess, on behalf of the California Alliance of Child and Family Services, in support.

Molly Robeson with Planned Parenthood affiliates of California, in support.

Dylan Elliott. On behalf of the California State Association of Psychiatrists, currently with a support, if amended position. Really appreciate the author's intentions with the bill. Would just like to see the phrase behavioral health make it in offered, friendly additionally.

Name. Oh are doing two.

Yeah one more. I apologize, Madam Chair. On behalf of the California Medical Association, in support.

On behalf of the National African American Civil Rights Chair, we support.

Hello. Dominique Paxton with California Black Women's Health Project. We support.

Thank you. Any witnesses in opposition? Seeing none. I'll bring it back to the Committee for comment or questions. Seeing none. Doctor Jackson, thank you for bringing this forward. You continue to be a leader in the space, particularly around mental health and behavioral health, and particularly for black Californians. So I very much appreciate your leadership on this, and if you are open to it, I would love to co author this bill. Thank you. With that, you may close.

Thank you very much, Madam Chair. The research is clear. If you the best way to be able to serve someone, particularly in anything, in terms of their, any of their health needs. Cultural competency is essential, but cultural competency has to go further than just saying.

I recognize that there's differences and people believe in different things, but until you really begin to be trained on the cultural context of a specific population and the way they receive information and the way they want to be served from a historical context, the specific types of issues that are unique to that specific population, such as historical trauma, racial stress, all those type of things, go into the issues that are affecting African Americans.

So no matter who is serving an African American, and most likely won't even be an African American. So to be able to provide an opportunity to get that type of training so that they can do just a little bit better, to be able to help the population, makes a world of a difference. I respectfully ask for an aye vote.

Thank you. And we will look forward to that motion once we have a quorum. Thank you, Doctor.

Oh, yeah, I forgot. I can join your Committee. And I can.

I would love that. Please. Please. We will move forward with item number 18, AB 24. Apologies.

We will move forward with item number 13, AB 2297, Friedman.

Thank you, Madam Chair and Members. Medical debt is a significant driver of bankruptcy, poverty and racial inequities. Over a third of Californians report having medical debt, and hospital debt alone makes up over 70% of all medical debt. In 2006, California created the hospital Fair Pricing act to protect patients. Many of you will recall our recent updates to the act in 2021, including AB 532 by Dr. Wood and my bill, AB 1020.

While the patient provisions we put into law are working, we're also learning of areas where we need to strengthen the code. AB 2297 does the it defines charity care, distinguishing it from discounted care or financial assistance clarifies that hospitals must review applications for charity care or discounted care without arbitrary deadlines prohibits the use of.

Liens on property to collect unpaid medical bills from financially eligible patients and eliminates the consideration of assets from eligibility, consistent with current Medicare rules. It's important to remember that these patient protections apply only to uninsured and underinsured patients with an income under 400% of the federal poverty line.

For patients with limited resources, medical debt can be devastating, putting them at risk of housing instability and financial ruin. I believe that in a country as wealthy as the United States and a state as wealthy as California, the whole concept of medical bankruptcy and medical debt for someone who is just trying to save their life or the life of a loved one is a complete, it's really unacceptable. It's an abomination, is what it is.

And the fact that we are taking people's homes and property or putting a lien on their home just because they want to get treatment for a sickness is something that shouldn't happen. This bill strengthens the safety net for patients in need. As you'll hear from the California Hospital Association, we are continuing to work with them on language to address their concerns.

The Committee analysis notes two of those amendments, which further clarify the definitions for charity care and discounted payments, and allows hospitals to consider a patient's health savings account when determining eligibility. We'll also continue our conversations with the California Association of Collectors, especially as we move into the Assembly Judiciary Committee.

And I will say that some of.the concerns of the hospital Association can be addressed by the hospitals themselves in terms of the amount of time that can go by. If they would provide patients with very clear information about how to apply for debt relief and how to apply for charity care, then maybe they wouldn't have to worry about people popping up later.

When they basically are in financial ruin, realizing that they would have been eligible. This is something that can be done if information is given to people in a language they understand, presented to them clearly, not buried in some stack of medical bills and paperwork at a time when people are the most vulnerable, when they're leaving the hospital sick and after major surgeries.

So there are ways that we can deal with these issues without putting the burden on critically sick individuals. With that, I have testifying in support today, Linda Wei from the Western Center of Law and Poverty and Umberto Cruz from La Puente. Thank you so much for your consideration.

Good afternoon. My name is Umberto Cruz and I'm here to share my family's experience following the birth of our child in 2010, my wife and I welcomed our first child at Queen of the Valley Hospital in West Covina, California. Our joy quickly turned to concern when our newborn required emergency services at an extended stay in the NICU. Despite having what I believe to have been adequate insurance coverage through my employer, we were blindsided by the exorbitant medical expenses that were not covered by our insurance.

The hospital failed to inform us about the option to apply for financial assistance, leaving us with a staggering bill. This was just the beginning of a long and distressing journey throughout medical, debt and financial insecurity. In the years to follow, the situation only worsened. The hospital did not provide any guidance on managing the debt and therefore we knew it. Our account was sent to a collection agency.

As a result of my inability to take time off from my new job to appear in court, a default judgment was entered against me. To make matters worse, we were forced to sell our home to my in laws, only to discover that there was a lien on the property due to the outstanding medical debt. Despite our best efforts to make payments, the collection agency continued to pursue us relentlessly.

They seized $17,000 from the sale of our in-laws home and placed levies on my personal bank account. Over the course of 12 years, my family and I paid nearly $23,000 to collection agencies, draining our savings and accruing credit card debt in the process. This ordeal has a profound impact on our lives. We have struggled to maintain financial stability and the stress and uncertainty to take has taken tolls on us.

The $23,000 that were forced to pay could have been used to secure our future pay, our children's expenses and overall stability. Instead, it has been lost to a system that failed to provide us with the support and assistance we desperately needed. I share my story not only to seek justice for my family, but also to advocate for a greater awareness and reform in our healthcare system. No family should have to endure the financial devastation that we have faced simply because a medical emergency.

It is time for change and I hope that my sharing my experience can work towards a future where no one must choose between their health and their financial security. Thank you.

Good afternoon. Linda Wei with Western center on Law and Poverty, proud cosponsors of AB 2297 which would prohibit the use of home liens in the collection of unpaid hospital bills from court financially qualified patients.

Unfortunately, these property liens are regularly used to collect unpaid medical debt, as evidenced by review of county assessor records and fellow witness Mister Cruz here today. In addition, the bill would eliminate asset consideration in financial assistance determination to align with Medi-Cal eligibility rules, simplify the financial assistance application process, and help protect California savings from being depleted when seeking hospital care. Californians need their savings to prevent poverty and retirement and older age.

As of 2019, 7.4 million Californians aged 25 to 64 do not have access to an employer sponsored retirement plan and nearly half of Californians private sector workers have no retirement assets at all. Finally, the bill would clarify that hospitals must review financial assistance eligibility at any time and prohibit application deadlines for financial assistance.

Our legal aid advocates regularly assist clients who are denied financial assistance due to arbitrary deadlines that disqualify them. HCAI or the Department of Healthcare Access and Information, which enforces the Hospital Fair Pricing act, interprets current law to prohibit deadlines for application and this would clearly reflect this. We urge your support of this bill to provide much needed relief for large hospital bills for low and moderate income patients. Thank you.

Thank you. We'll ask for any other folks in support of the bill. Your name, organization and position only.

Thank you. Dylan Elliott on behalf of the California State Association of Psychiatrists in support thanks.

Katie Van Dynes with Health Access California and support thank you

Beth Blandowski with SEIU California in support.

Hi, Janice O'Malley with AFSCME California in support.

Yasmin Peled with Justice and Aging in support.

Thank you. Do we have any opposition? Please come forward.

Good afternoon. Chair Members of the Committee, Rony Berdugo here on behalf of the California Hospital Association. Respectfully, we are opposed unless amended. But I'll be brief because although we are still seeking amendments, the author, the sponsors and Committee staff have been great in working with us in trying to find reasonable solutions to our ongoing concerns. With that being said, we especially appreciate the amendments that have been taken so far. We definitely think that that is a step in the right direction.

Our ongoing concerns are really centered around conformity with federal laws and regulations that prevent providers from offering so called incentives, and I'd only put quotation marks on that because they can be pretty strict about that. So things like free discounted care, copay, and deductible waivers for using our services could be considered incentives, and they could only be provided to patients strictly based on their individual financial need, including assets. And so without that, the Office of Inspector General considers those waivers as fraud and abuse.

And so I think it's important for us to have clarification around that. Finally, we also think that there should be some reasonable deadlines on when patients can apply for or become eligible for charity or discounted care. But I do think that these are all issues that hopefully can be sorted out with ongoing conversations with all of the stakeholders. So with that, thank you.

Thank you. Melissa Cortese, on behalf of the California Association of Collectors, our primary concern with this bill is the provision to preclude hospitals or their assignees from collecting or obtaining a lien against any real property, not just the patient's primary residence. We believe this is an unnecessary expansion of existing law which already protects the patient's primary residence. So now we're looking at patients with second homes, vacation homes, where we wouldn't be able to lien on those.

We look forward to working with the author as this bill moves forward. Thank you.

Thank you. Are there other witnesses in opposition?

Support. Sorry for the delay. Sawait Seyoum on behalf of Disability Rights California, we're in support.

Thank you. So, seeing no witnesses in opposition. Okay, we can bring it back to the Committee for comments, questions.

I just want to thank the author for bringing this forward and the sponsors. I think this is a really important issue. You know, medical debt and medical bankruptcy continue to be the number one reason for bankruptcy in the United States year after year after year, and costs are going up and up. And I've worked specifically on the charity care issue. And the issue around charity care is that most people don't know about it.

And they're not informed, and it's not really shared as an option for patients who really need it. And so I think this is a really important protection to provide for patients. And just a piece of the puzzle. To make sure that people are not. Put in financial ruin just for seeking care that they need. Thank you. And I'd love to be a co author.

Thank you. We'd love to add you.

Thank you. Any other comments from the Committee seeing? None. We don't have a quorum yet, so I'd ask the author if you'd like to close.

Yeah. We will continue to work with the Hospital Association and the debt collectors to try to address any reasonable concerns. We certainly want to make sure that it works for everybody. And I know that there are some technical issues in terms of definitions and others and other laws that we need to work around. So we'll continue to work with them.

I will say, in terms of the other real assets, there are people who have an apartment unit or a townhouse, that is their retirement. They may not have a huge source of income. They may have had that piece of property for a long time. They're relying on that to pay for themselves in retirement. And that's why we are trying to protect those assets from being seized to collect debt that could throw those people into poverty when they've been waiting their.

Whole lives or relying their whole lives on that early investment. So there are reasons, you know, I understand if someone has, you know, a whole bunch of second homes, but they probably don't qualify for charity care in any case. But we'll work to make sure that we can still protect, you know, people's remaining assets as we move forward.

But that is the rationale behind that. And with that, I would request an aye vote so we can continue to work on this.

Thank you. Great. Thank you. And we will take a vote as soon as we get a quorum.

We have so going. In some kind of order on our agenda, Ms. Petrie Norris can present item 10. AB 2169.

Good afternoon, Madam Chair and members. The committee was kind enough to place my measure on consent today. Thank you. But I am still here to present on behalf of our colleague, Assemblymember Bauer Kahan, AB 2169. AB 2169 authorizes prescribers to adjust up to two times the dose or frequency of a drug without a prior authorization, as long as the drug has been approved for coverage by the plan, and the plan's prescribing provider continues to prescribe it.

In California alone, 38% of our residents are living with one or more chronic medical conditions. Prescription medications are often a lifeline. However, the road to finding effective treatment is fraught with challenges. Providers may need to adjust medication over time to optimize results. Unfortunately, each adjustment right now requires approval from health plans, a process that all too often ends in denials or lengthy appeals. These create powerless delays in treatment.

For example, in 2021, a staggering 87.5% of patients suffering from inflammatory bowel disease, IBD, had to appeal their insurance denials before ultimately receiving approval. Oftentimes in that situation, by the time a decision is rendered, patients may have experienced worsening conditions or have been forced to switch to alternative medications, which limits future treatment options. IBD is just one example of many chronic illnesses where inadequate medication dosage can lead to severe complications, even life threatening ones. With me in support today is Lisa Lum and her son Trevor.

Good afternoon Madam Chair and Members. My name is Lisa Lum. Thank you for letting me speak today on behalf of my son Trevor, who was diagnosed with Crohn's disease two years ago at the age of nine. On November 1, 2022 Trevor was placed on Remicade. Our insurance approved the first three infusions a few weeks apart and then a maintenance every eight weeks.

Unfortunately, he did not have the optimal levels after the third infusion, so the doctor requested to change the maintenance from every eight weeks to every four. On December 20, the first denial stated lack of medical necessity. His doctor appealed and asked for an expedited review, which was also denied. On January 21, a second denial came, stating again lack of medical necessity, even after multiple phone calls and submitted documents from the doctor and myself.

This was now six weeks after Trevor's last infusion and he had been home from school with increased bloody stools and had to start on steroids because of all the waiting. We made a third and last attempt to ask for an increased dosage amount at the eight week infusion and again denied. On January 25, I submitted an independent medical review complaint to the Department of Managed Healthcare.

On January 28, after just two days of the department's involvement, the insurance finally approved the four week interval dose, admitting that it was indeed a medical necessity and Trevor's now receiving a dose every four weeks. It was a very emotional and frustrating time in our lives, seeing our young son in pain and bleeding. We were worried, desperate, and at the mercy of the insurance company. Luckily, I'm a stay at home mother and I could devote my time to this situation.

If his medical team and I didn't advocate so fiercely for Trevor, I don't know how much longer he would have suffered. We are here today hoping Trevor's story could provide another perspective on this matter and could make a difference in forwarding the treatment of this disease. Thank you.

Thank you, Miss Lum. And thank you, Trevor, for being here and sharing your story with us. And Ryan Spencer is also here on behalf of the Crohn's and Colitis Foundation for any technical questions that committee members may have.

Okay, thank you. Do we have any witnesses in support to add on?

Ryan Spencer, on behalf of the Crohn's and Colitis Foundation, we are sponsors of the measure and support.

Good afternoon. Dylan Elliott, on behalf of the California State Association of Psychiatrists and the California Medical Association, in support. Thank you.

Thank you chair and members. Tim Madden, representing the California Rheumatology Alliance in the California Chapter of The American College of Cardiology, in support.

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

David Gonzalez, on behalf of the California Life Sciences, in support.

Kim Stone, Stone Advocacy, on behalf of the California Orthopedic Association, in support.

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

Thank you. Do we have witnesses in opposition? Please come forward.

Good afternoon, Madam Chair, members of the committee, Jedd Hampton with California Association of Health Plans, regrettably here in opposition to AB 2169. First and foremost, we'd like to thank the author, who I know is not here today, but appreciate assuming member patron owners filling in the committee staff as well as the sponsors. This is an issue that we have been working on for a few years now. I'm really trying to get to the right spot.

We really appreciate the sponsors engaging us on this and continuing to find a way forward. Regrettably, though, from our perspective, it's not quite there yet. Health plans rely on several critical utilization management protocols to ensure that patients receive the right care at the right time from the right provider, and these protocols are critically important to promoting safe, effective and affordable care care for health plan enrollees.

Regrettably, AB 2169 would remove our ability to review the clinically appropriate use of a prescription drug when the dosage of the medication is increased, which we believe could lead to several unintended consequences. It is important to note that when health plans choose to limit the increased dosage of a drug, it's usually for safety reasons. It's generally also used to ensure that these medications are used consistent with FDA approved labeling and prescribed doses that have been shown to be efficacious.

Regrettably, this bill does not include language that would require the drug to be prescribed consistent with FDA labeling or prescribed for something that is consistent for which the drug has been approved for the FDA. So we are concerned about the ability in this bill that limits our clinical oversight and ensures that the medications are prescribed consistent with FDA approved labeling. Lastly, we do believe that this bill could lead to increased costs in healthcare delivery.

We would acknowledge that this bill is much more limited in scope than previous iterations. So we don't think that the costs are going to be quite as high as previous iterations. But we do believe that this bill will potentially harm affordability by encouraging the use of expensive specialty and brand name drugs when a generic or lower cost brand is equivalent. So for these reasons, we are currently opposed. Again, appreciate working with the author and the sponsors. Look forward to having those conversations moving forward. Thank you.

Stephanie Watkins on behalf of the Association of California Life and Health Insurance Companies, I would echo many of my colleagues comments. We, too would like to extend our appreciation to the author and the sponsor. As was mentioned, we've worked on this bill I think for three years now, and it's in the current form is much more narrow. We appreciate the sponsor's interest in addressing our concerns at this point. Regrettably, we are opposed.

I think when you really look at the breadth of this bill, the lion's share does touch our entire formulary, which while we can appreciate in certain instances it makes sense to increase the dosage or increase the times that something is given. But given the breadth of this bill and how broad it is, and that it does cover our entire formulary, with some exceptions, we do have some concerns. We'd like to continue those conversations, especially around the FDA approval, especially if the bill moves forward to that.

Thank you.

Thank you. Do we have additional witnesses in opposition?

John Wenger, on behalf of America's Health Insurance Plans, would just align our comments with cap and acolyte.

Thank you. Bring it back to the Committee. Yes, Ms. Schiavo.

Just wanted to see if there was a response to concerns from the opposition.

I will let our sponsor reply since I don't want to speak out of turn on the author's back.

Thank you. Well, a couple things. I think the issue that we're talking about here is not about some experimental drugs, some high cost drugs that the plan hasn't already approved and covered. We're talking about a drug that the plan has approved and covered and has been prescribed to the patient, and they're stable and the drug is working. So all we're asking for is for that provider to be able to optimize that drug, which the plan has already approved coverage for to the fullest extent possible.

Because the only other option that the provider and the patient has is to move off of that drug and go to another drug, which there are a limited number of drugs out there, particularly for IBD patients. And that drug may or may not work, but they know this drug did at one point and so if they can maximize that dose, they'll be able to do that.

Now, when you're talking about the FDA approval, which is a question that came up, sometimes the FDA will approve it for, say, in our case, infusions takes eight weeks. For an infusion, six weeks would be considered off label, but it's still the same drug. And, but yet the, the levels are lower in the patient. So the only way you can increase that level of that same drug is to optimize the dose instead of going eight weeks to six weeks. Technically, that would be off label.

But that is what the medical provider who sees this patient every so often, but frequently, unfortunately. And they know the needs of their patient better than the health plans, frankly. And so that's what I have.

Thank you.

Any other comments or questions from the committee? I just want to say that, you know, when we're talking about chronic conditions, we can see a lot of times how something could cause a spike, something if the patient is stable, then all of a sudden there's a stress situation, or sometimes sunlight, or sometimes some mixing with another drug that is temporarily taken or something like that could cause a spike in the symptoms.

Or in some cases, maybe the patient's doing much better and they need to lower it. But in those cases where, and I think it's more critical where you're looking at having to increase a dose, it seems to me that the timing is so, so critical that they get access to that drug. And, you know, if there's a way to streamline the process, whatever it is, and I understand what you're trying to do.

So we don't have a quorum, obviously, we're far from it, so we don't, we can't do a motion, but we will be taking up the bill when we do. And would you like to close?

Yes. And thank you for those comments. On behalf of the author, I'll simply say, I know it's the intent of the author to establish really robust guardrails and parameters to ensure that this is not subject to abuse. And that's why it's limited to situations where a specific drug has already been prescribed and situations where the prescriber continues to be the same prescriber.

Again, on behalf of the author, I know that she will continue conversations and continue to work with the concerns of the opposition and ensure that we have a policy moving forward that keeps kids like Trevor here safe and healthy. So with that, at the appropriate time, on behalf of Assemblymember Bauer Kahan would respectfully ask for your aye vote.

Thank you so much. Thank you. Okay, Assemblymember Calderon going in author order file number 18 AB 2428 and she also has file 28 AB 3030.

Good afternoon, chair and members. Assembly Bill 2428 would require MediCal managed care plans to reimburse community based adult day service providers at a rate equal to or greater than the amount paid by the Medi Cal fee for service delivery system. Community based adult day services offer an alternative to nursing home care for thousands of low income seniors living with chronic medical disabilities and mental health conditions. Providers are reimbursed through contracts established with managed care plans for services provided to Medi Cal recipients.

In 2011, a series of Medi Cal cost reduction measures led to a 10% provider payment reduction, which was restored in 2019. Despite the rate restoration, adult day service providers have struggled to keep centers open as some managed care plans have failed to fully restore rates. Without immediate intervention, these centers will continue closing, leaving thousands of high risk elderly Californians with no place to receive services. This bill will ensure that a vulnerable and growing population of elderly Californians can still access these services for years to come.

With me in support of the bill are Kawon Lee, board of directors, President of the California Association for Adult Day Services, and Lydia Missaelides, interim executive director of the California Association for Adult Day Services.

Good afternoon, Madam Chair and Members. I'm Lydia Missaelides. As Assemblymember Calderon said, representing ommunity based adult services throughout the State of California. Assemblymember talked about our background. I wanted to just add that this program is authorized under the state's CalAIM 1115 waiver, and this program was the first long term services and supports program to be swept under the auspices of Medi Cal

managed care back in 20 was around 2011-12 and then the Great Recession hit, and as assembly member said, provider rates were slashed 10% across the board to help balance the budget.

When the state budget improved and the legislature and the governor restored the provider rates back to that pre recession level on July 1, 2019 all parties expected that the managed care plans would understand your intent to restore CBAs rates because, as your bill analysis points out, the capitated rates for the managed care plans took this into account. So the plans were made whole for all of those plans that were paying below that rate.

After hearing from many providers frustrated in their attempts to get these insurance companies to restore their rates, we had to jump in to help. We identified four managed care plans, as the analysis describes, that continued paying the reduced rate enacted by the legislature. Even though they are only four plans, they represent a large number of these contracted CBAs providers.

After countless Zoom meetings, emails, documentation, and let's not forget the pandemic, two of these plans began in 2022 to take the necessary steps to retroactively make their contracted centers whole. But two other plans remain what I'll call a work in progressive this is neither an efficient nor a sustainable process for our small providers or the association to undertake. That is why we want to thank Assemblymember Calderon for jumping out to help us and put in place this preventive policy.

And Kay, my President of the Association this year, will describe the unique position that cbas are in and why this is so important.

Thank you again. My name is Kay Lee and I'm the president of the board of directors of the California Association for Adult Day Services. As a board member, I am one of the many small, nonprofit and usually family business organizations that serve as the adult day healthcare CBAs providers throughout the state to provide needed services for our participants, most of whom are from historically underserved and vulnerable communities.

However, the many difficulties of being a small community based provider have created ongoing barriers for both providers and participants. Since cbas centers have transitioned to working with managed care organizations, we've been faced with many of the challenges associated with such relationships and where there is a clear power imbalance, many providers do not have the resources or the power to negotiate contracts despite ostensibly being told that they are free to do so.

As you'll see in the analysis, what is left are take it or leave it contracts, which are with providers having to agree to low reimbursement rates that do not come close to covering the actual costs of care that continue to rise year after year. And so, without agreeing to these contracts, large swaths of the state would be left without any providers able to serve these Medi Cal communities. Because of the lack of Medi Cal providers in large parts of the states and within community based settings.

Moreover, CBAs centers are unique because our programs universally serve a high number of Medi Cal beneficiaries, with many providers enrollment speed being 100% all Medi Cal beneficiaries, and being uniquely positioned to continue to provide care because it is by design placed to serve high risk populations and so providers have no other options for financial resources or payer sources with better reimbursement rates.

All of these financial pressures continue to contribute to an impending crisis in which CBAs centers may be unable to continue to provide services for communities throughout the state. We therefore respectfully ask for your aye vote to help partially mitigate financial the financial ruin of a lot of these programs and to protect CBAs centers and the communities proactively and to serve as a protection for any future cuts.

Thank you. Thank you. Are there additional witnesses in support? Name organization only.

Madam Chair and members, Monica Miller, representing Alzheimer's Orange County, Alzheimer's San Diego and Alzheimer's Los Angeles, in support, and we thank the author. Thank you.

Yasmin Peled, with Justice in Aging, in support. Thank you.

Peter Hansel, advocacy volunteer for AARP California on behalf of AARP and its 3.2 million members in support of the bill.

Good afternoon. Ryan Souza, on behalf of Leading Age California, in support. Thank you.

Thank you. Do we have any witnesses in opposition? Seeing none. Bring it to the committee. Comments? Questions? This is a good bill. May I be asked, I don't know if I'm already on as a co author or not, but I'd like to be.

Thank you. And I'd love to add you as co author.

Anyone else? No? Okay, well, we don't have a quorum, as I stated before, so we will take up the bill. When we do, would you like to close?

Yes. I respectfully ask for an aye vote at the appropriate time.

Great. Thank you so much. Now, you do have a second Bill. Item 28, AB-3030.

The Chair and Members. Assembly Bill 3030 would require healthcare providers to point AI for patient communication to disclose the technology's usage. I'd like to start off by thanking the Committee for working with my staff on this Bill, and I will be accepting all the Committee's amendments. Across the state, pilot programs are testing the use of generative artificial intelligence, or GenAI, as a tool to assist clinicians with patient communications.

For instance, UC San Diego Health currently has a pilot integrating GenAI into MyChart. A platform where providers can message with their patients. As healthcare providers deploy GenAI, patients should be aware of who they are communicating with to ensure confidence in the healthcare that they're receiving. AB-3030 is a good governance Bill seeking to advance the ethical use of AI Gen in healthcare. And I don't have any witnesses. I have staff for technical questions.

Okay, great. Thank you. Are there additional witnesses in support in the audience? Seeing none. Any opposition?

Good afternoon. Vanessa Gonzalez with the California Hospital Association. And we're not in opposition. We actually don't have a position on the Bill at this time. However, we do have concerns with the proposed Committee amendment to strike the language protecting hospitals and providers from civil and criminal liability. Appreciate the discussions that we've had with the author and staff, and look forward to the continued discussions. Thank you.

Thank you. Seeing no additional opposition, bring it to the Committee. Any comments?

Just quick. This is going to privacy after this?

Correct.

Okay. I'm not going to Julia it, you're going to get that later.

Yes, I will. Thank you.

No, but thank you, because this is such an incredible topic right now, and so we need to address it at all levels. So thank you very much for bringing it forward, bringing it to light for all of us sitting up here at the dais.

Thank you.

Thank you. Would you like to close?

Yes. This is, you know, this is a nuance. It's a new kind of area that we're looking at in terms of policy, and it's so important for all of our future. So I am committed to continuing to work on the Bill, and I respectfully ask for an aye vote at the appropriate time.

Thank you. Okay, Mr. Gabriel, you've been very patient. You have a number of items to present. Item 20, AB-2550.

Thank you very much, Madam Vice Chair and Members. I want to start by thanking the Committee for their thoughtful feedback and assistance with this Bill. I am pleased today to present AB-2550, a measure that will support California's small businesses by cutting red tape and removing outdated or needless regulations that drive up costs for neighborhood restaurants. Neighborhood restaurants are the backbone of communities across California and employ one of the most diverse workforces in our state.

But too many are struggling in need of regulatory flexibility to help them recover from economic losses associated with the pandemic and rising inflation. AB-2550 was written in partnership with small business leaders to address these issues head-on. It provides appropriate flexibility so that restaurants can make design decisions that are best suited for them and their customers. The regulatory flexibility this Bill provides is not a mandate, but creates a set of options, guided by experts to allow small restaurants to flourish.

We've been in conversation with local environmental health experts and regulation enforcement professionals and expect that we will refine the Bill as it moves through the process. AB-2550 is supported by a broad coalition from across California that includes the Los Angeles County Business Federation, the California Restaurant Association, and numerous chambers of commerce. There is currently no registered opposition for this Bill.

With me today to testify in support of the measure are Eddie Navarrette, the Executive Director of the Independent Hospitality Coalition, and Vanda Asapahu, Owner and Head Chef at Ayara Thai, a family-owned Thai restaurant in Los Angeles. Thank you and respectfully request your aye vote thank you.

You'll each have two minutes.

Thank you, honorable Members. My name is Eddie Navarrette, Executive Director at the Independent Hospitality Coalition. The independent Hospitality Coalition is an organization of hospitality operators, advocates, and workers whose whole purpose is to provide community support and awareness of our role in the economic fabric of society.

Today, speaking on behalf of a diverse community of neighborhood restaurants throughout the LA County landscape. Members, media outlets such as the Fresno Bee, the SFGATE, LA Times, Wall Street Journal, and more have all reported substantial losses to our community within the last year. Post-pandemic businesses have been faced with some of the largest challenges, from increased costs on everything, environmental challenges, and red tape. Red tape creates barriers for underserved communities, making the American dream much less attainable.

The layers of outdated, contradictory policies that exist do not reflect the progress of our industry. AB-2550 is an adaptive reuse initiative for small business by lowering the barriers to entry, supporting an already struggling community, and supporting investment into our older building stock, reducing carbon emissions from new construction. We propose updates to a few handfuls of outdated, low to no-impact code sections that give small business owners tools to rebuild existing businesses or to build new ones. Fostering small business growth and equity in our communities. These updates will give exceptions in areas where local jurisdictions are powerless, while insignificant to a larger business.

To a smaller business, they may make all the difference. On behalf of small business owners, local chambers, and community associations, we look forward to your aye vote in moving this important piece of policy forward. Thank you.

Hi, my name is Vanda Asapahu. I'm a Chef and Managing Owner of my family's restaurant, Ayara Thai in Los Angeles. My family moved to LA when I was five. My parents have opened and closed numerous restaurants in Los Angeles. I grew up as a restaurant kid, like many, doing homework in the storage room and helping where I could after school and on weekends.

For my parents, running a mom-and-pop restaurant was back-breaking, made challenging by increasing costs and the layers of complexity to comply with government regulations. Seeing my parents sacrifice to create for our community compelled me to return to the industry in 2012. That was the year I helped my parents achieve the American dream as small business owners by taking out a loan and purchasing the building that houses our restaurant and the unit next door.

That was also the year I learned many hard lessons about this industry. My goal was to combine the two units to meet the growing demands of our thriving restaurant without bringing in investors. I was immediately faced with costly and time-consuming permitting obstacles. Many of the regulations were outdated and over-restrictive with no bearing to the health and safety of the public. I'd like to share you a personal example.

We were told to put in a below-ground grease interceptor that would cost upwards of 100k, require extensive digging, and would take two to three months to complete. The alternative above-ground interceptor would cost only 30k and could be installed in one week and could easily be accessed for maintenance and cleaning and has far less environmental impact. Due to this and other obstacles, construction is still not completed. This Bill will solve that problem.

This Bill, AB-2550 will help small businesses like my family alleviate unnecessary regulatory burdens to open or grow their restaurants. This Bill proposes exceptions to allow for above-ground grease interceptors to be installed in kitchens and other regulations to foster economic growth for restaurants. Thank you.

Thank you. Are there any other witnesses in support?

Thank you Madam Chair and Members. Matt Sutton of the Restaurant Association. Really appreciate your support of the Bill today. Appreciate the author's leadership here. Continue to bring restaurant issues into your Committee, which I know is a bit of a change for your jurisdiction, but thank you. We are in support of the Bill.

Thank you.

Hi, Carol Gonzalez here on behalf of Inclusive Action for the City. In support. Thank you.

Thank you. Any witnesses in opposition? Seeing none. We'll bring it back to the Committee. Seeing no comments. Mr. Gabriel, you may close.

Thank you very much. Madam Chair. As you know, supporting our neighborhood restaurants has been something that we've been working on since the COVID-19 pandemic that began with AB-61 to provide regulatory relief. We had the good fortune of having that Bill signed at a delicious neighborhood restaurant in your district, as you, I'm sure you recall. And you know, the challenges that these folks continue to face with inflation is significant, as you heard, and so would respectfully, at the appropriate time, request your aye vote on this Bill.

Thank you. We will move on to your next item on the agenda, which is item 22, AB-2700. Please go ahead.

Thank you very much, Madam Chair and Members, let me again start by thanking the Committee for their thoughtful work on this Bill. We are happy to accept the Committee's proposed amendments. I am pleased today to present AB-2700, a measure that will connect people experiencing a behavioral health crisis to care facilities such as crisis stabilization units and sobering centers. Ultimately, this Bill is about making sure people can get the right care at the right time, in the right place, and in the right manner.

Currently, state law limits where ambulances may transport an individual experiencing behavioral health crisis. As a result, individuals in crisis are taken frequently to overcrowded and overwhelmed emergency rooms that may have strain resources to address their behavioral health needs. Over the last few years, researchers have studied the impact of several local pilot programs that have allowed ambulances to transport individuals experiencing behavioral health crisis, to an alternate destination. These pilots have produced encouraging results.

An independent evaluation of these programs by the University of California, San Francisco, found that transport to alternative destinations considerably lowered ambulance patient offload times, meaning ambulance crews could respond more quickly to other 911 calls. Similarly, law enforcement spent less time on behavioral health transports, which freed them to focus on their public safety responsibilities. These efficiencies are critical as we face a daunting mental health care crisis.

Tens of thousands of individuals battling addiction and mental illness are trapped in a relentless cycle, cycling through hospitals, jails and homelessness. Our hospitals are often stretched beyond capacity. This Bill will ensure that we plan and prepare at the local level to make use of safe medical treatment options available in dealing with the behavioral health crisis in our state.

I'm grateful for the continued collaboration and conversation with the California Professional Firefighters, the emergency room physicians, and the California Nurses Association as we work very closely to address the concerns raised. With me today to testify in support of this measure are Tara Gamboa-Eastman, Director of Government Affairs at the Steinberg Institute, and Christie Gonzales, Chief Programs Officer at Wellspace Health. Thank you. And at the right time would respectfully request your aye vote.

You'll each have two minutes. Thank you.

Good afternoon, Chair and Members. Tara Gamboa-Eastman, with the Steinberg Institute, the proud sponsor of AB-2700. This Bill is about more than expanding successful triage to alternate destination programs. It's about expanding them at the right time. The Legislature has championed some of the biggest reforms to behavioral health crisis system in the country.

You passed AB-988 to implement the new National Behavioral Health Crisis Line, which came with a promise, the promise that everyone in a behavioral health crisis will have someone to call, someone to come, and somewhere to go. You have invested billions of dollars into building these alternate destinations through the BHCIP program, with billions more coming as part of Proposition 1.

You have passed legislation ensuring commercial insurance coverage for crisis services offered at alternative destinations, and Medi-Cal is covering more of these services as part of CalAIM. California is in the process of fundamentally transforming its response to behavioral health crisis.

The next step is integrating our system so that people can access the services we have spent years and billions of dollars investing in. Right now, access to behavioral health crisis services are hampered by the fact that ambulances can't take people to the locations when that care would be appropriate. Triage to alternate destination program pilots have been operating for years and have been independently evaluated. Researchers have deemed these programs safe and effective.

We have a strong regulatory framework in place to ensure paramedics are appropriately trained and that patient safety is front and center. Now is the right time to expand California's triage to alternate destination programs to ensure everyone gets the help they need when they need it. Respectfully request your. I vote. Thank you.

Thank you. Please proceed.

Good afternoon. My name is Christie Gonzales, and I'm with Wellspace Health. Wellspace Health is a Sacramento-based nonprofit community health system that integrates medical healthcare, dental health care, behavioral health care, and other supportive services, such as being a 988 suicide and crisis line provider for over 32 counties in the state. Recognizing that there needs to be a real-world solution to California's behavioral health crisis, Wellspace Health has created a continuum of crisis care right here in Sacramento County.

Key to that crisis system is the Crisis Receiving for Behavioral Health, affectionately known as CRB. Located in downtown Sacramento, it's a dedicated location, open 24 hours a day, seven days a week, and it was opened in 2020 at the height of the pandemic, when there was elevated criteria to be able to get into the ED and get into the emergency room. We wanted to make sure that there was a place for people in behavioral health crisis to be received immediately.

Since opening in 2020, we have provided more than 9,500 behavioral health crisis sessions. Of those patients seen since 2020, 7% of them have voluntarily gone on to seek behavioral health services and only 2% of them have needed some higher level of care, such as an emergency department visit. Wellspace Health's CRB is currently designated as a CalAIM sobering center and certified as an outpatient crisis stabilization services by Sacramento County's mental health plan.

In 2020 and 2021, CRB was designated as an alternative destination under Sacramento County Emergency Medical Services Agency's COVID-19 era assess and refer policy, and we are currently included in the county's plan for future alternate destination programs. At CRB, there is a patient offload time of only three minutes. Patients are currently referred into CRB by authorized referral partners such as 988 team, and we hope to include emergency medical professionals in that. We urge your aye vote.

Thank you. Are there any other witnesses in supports and while they're coming, if there are any witnesses, primary witnesses in opposition, please come forward. Please go ahead.

Good afternoon. Glenn Backus for the Prosecutors Alliance of California and the Ella Baker Center for Human Rights. In support.

John Drebinger with the Steinberg Institute, sponsor the Bill. Also expressing support on behalf of, The Kennedy Forum and Californians for Safety and Justice.

Thank you.

Leah Barros, on behalf of California Hospital Association. in support.

Jim Murphy, on behalf of the California Association of Alcohol and Drug Program Executives. In support. Thank you.

Any primary witnesses in opposition?

Thank you, Madam Chair. I'll be really brief. Doug Subers, on behalf of the California Professional Firefighters. As noted in the analysis, we do have an opposed unless amended position on the Bill, but we've been working diligently with the author on amendments that not only would address our concerns, but also move CPF to support. So we really like to thank the author for that engagement and look forward to working to finalize those amendments so that we could get to that position. Thank you.

Madam Chair and Members.Tim Madden, representing the California Chapter at the American College of Emergency Physicians. We're also in an opposed unless amended position. Did want to thank the author and the sponsors for their conversations. We're encouraged with the author's comments on addressing our concerns and look forward to continuing those conversations.

Additional, we'll offer just the name, organization, and position. Thank you.

Good afternoon, Madam Chair. Mari Lopez, California Nurses Association. Unfortunately, we are in opposed as well, with concerns with the elimination of the emergency rooms as a default for consideration for patients with considerations for behavioral health, but continue looking forward to working with the office. Thank you.

Thank you. I'll bring it back to the Committee for any questions or comments. Yeah, thank you, Mr. Rodriguez.

Yes, thank you. I want to thank the Member for bringing this Bill forward. Obviously, EMS is in my backyard for doing over 30 years, and I'd like to see where we're going. We're definitely changing the way we're providing, especially emergency care in our streets throughout the state, where we're looking at. A couple of concerns I have as this Bill looks to move forward is what is. I know the Steinberg Institute is one that's the sponsor and doing a lot of this work.

So what do you talk a little bit about the education and training. So what's being differently trained or educating our first responders to know that when they show up on a call that this isn't really a medical emergency, this is a mental health crisis or maybe a sobering center or whatever's doing. Because my biggest fear is, as first responders, you're not doctors, you're not supposed to diagnose. So now you're going to make these folks diagnose right. In a way that never been before.

But what training is being done differently to make sure that they are catching the right signs or signals that tell them what they should or shouldn't be doing with the patient?

Yeah. Thank you so much for the question. This Bill would look to expand an existing pilot program that included an additional training requirement for paramedics that would be doing this work. I believe it's over 100 hours of additional training that they would have to do to make sure that they are able to identify the appropriate signs and symptoms.

But the regulations for the existing pilot program that we would be making sure apply to this expansion, ensure that people are not transferred or taken out of the emergency room if there's a concern over a physical health condition. There has been very, very little people going back to the emergency room in the pilot programs. UCSF found that 98% of people were effectively served at the alternative destinations because the well-trained paramedics so able to make the appropriate call.

2% of people were taken back to the emergency room for a physical health condition, but then were ultimately taken back to the alternate destination, which we would see as a success. People ended up getting the care that they needed safely.

Yeah, as you stated. Yeah, because obviously a lot of these patients don't need to be in the ER. As you know, right now, if you go to any ER, half of them probably don't need to be there. The other thing I'm looking at, how do we make sure, maybe with the data that's being out to that there is a facility in every community. Right? Because just take Sacramento here, for example.

If our first responders go out and this patient needs to go to a mental facility and there isn't one nearby, and they got to go outside the city limits, what that does to the response time, because now you just took a unit out of service, so to speak, to go for an hour or so, depending on where they're at, you're taking them out of service.

Is there talk within the Bill or maybe Prop 1, we talked about to make sure there is a facility in each community? Because if not, I think we're going to have another issue with delayed response to other emergencies, because now we just took that unit out of service, so to speak. Right?

Yeah. Part of this Bill would be a gaps in needs analysis, assessing all of the facilities that we have statewide. One of the big problems that we have is we've invested billions of dollars but don't actually have a sense of what facilities are available locally. So we really want to get a good sense of what we have and what we need to get to the perfect vision of what alternative destination could look like.

In the meantime, absolutely happy to consider, you know, making sure that this works for especially our rural communities where we're not asking folks to, you know, go out of city limits or out of county limits, where it wouldn't make sense. We want to make sure that people have timely access to care.

Correct. But okay. There was just a couple questions, concerns I had, but I'm looking forward to supporting the Bill, and I think I might even come to my Committee next. I'm not sure, but just food for thought as this Bill moves along. And thank you again for bringing this Bill forward. Thank you.

It is true. Should this pass out of this Committee, it's going straight to you, Mr. Rodriguez. With that, Assemblymember, Gabriel, would you like to close?

Yeah. Thank you very much, Madam Chair. And I just want to thank, thank our colleague for those thoughtful points. I think you're hitting on exactly some of the conversations that we're having as stakeholders that we need to resolve. I also, of course, want to acknowledge your incredible lived experience in this area and the wisdom and insight that you bring here. So if we are able to pass a Committee today, look forward to continuing that conversation in your Committee.

I guess what I would offer is that we're really encouraged by the results of the pilot program. Right?: The statistics that the witness cited here with the fact that 98% of the time they're getting it right the first time, 2% of the time, folks are needing to go back to the ED, but then ultimately ending up back in that alternate destination. I think those are pretty encouraging statistics.

And as you mentioned, anyone who has been into an ED, virtually anywhere in the State of California recently understands the need for this Bill. So with that, at the right moment, would respectfully request an aye vote.

Thank you. I definitely appreciate your continued work with the current folks who are in opposition, particularly the firefighters and the nurses and the emergency docs, because they are our frontliners. And I'm sure that you will be able to continue to work on this to put it in good shape for moving forward with it. We will move on now. Thank you so much to your last Bill for the day. We should have just created a special session called Chair Gabriel's session, item number 26 AB 2899.

Thank you very much, Madam Chair, and we do appreciate the opportunity to discuss so many important issues in your Committee. So thank you for having us. And I want to also again thank the Committee for their thoughtful work on the bill and accept the Committee's proposed amendments. I am pleased today to present AB 2899 which will bring greater transparency to the way the California Department of Public Health responds to complaints regarding the violation of California's nurse-to-patient ratio laws.

Since the passage of key staffing ratio laws, the California Department of Public Health has held the important responsibility of enforcing these ratios. Despite the laws on the books, nurses have persistently raised concerns about continuous violation of the law within their workplaces. These concerns have been carefully documented through the submission of thousands of staffing complaints to CDPH.

AB 2899 will support workplace safety efforts and improve transparency by requiring CDPH to concurrently notify both the hospital and the individual who reported the violation, along with their collective bargaining agent or representative regarding the action to be taken for substantiated violations. Safe nurse-to-patient ratios are crucial for ensuring that patients receive the appropriate level of care and attention, and failure to adhere to these ratios can lead to errors, delays, and delays in care, and compromised patient safety.

It is our expectation with a little more sunlight and transparencies, hospitals will better adhere to the staffing law in order to maintain high-quality care for the patients and also a safe working environment for our frontline healthcare heroes. This bill has no registered opposition, and with me today to testify in support of this measure are Peter Sidhu, RN, Executive Vice President of UAC UHCP and Diane Smith, RN, a member of SCIU 521. Thank you, and at the appropriate time, respectfully request your aye vote.

Good afternoon. I would like to thank the Chair and the Members of the Health Committee for the opportunity to speak in support of AB 2899. My name is Peter Sidhu. I am the Executive Vice President of the United Nurses Association of, California, a union of healthcare professionals. But more importantly, I am a 20-year critical care ICU nurse. I've been through H1N1. Ebola, COVID, and I understand the stress of those times, but that's not what burned me out.

It was the chronic understaffing. Understaffing that made me, and many more like me, leave the bedside. When a nurse is consistently working in an understaffed unit, it not only places tremendous strain on the nurse responsible for managing more patients, but also the safety of that unit. Over time, these persistent violations of the nurse-to-patient ratios erode the trust in the regulatory system.

Because the laws established to safeguard and protect both nurses and patients are not effectively enforced. AB 2899 will require DPH to shed light on the determinations as to impose or not to impose a fine on a hospital for a nurse staffing ratio violation. Specifically, it requires DPH to provide a statement of reasons for not imposing a fine despite finding a substantiated violation.

The provision will also bring transparency to a process that is currently shrouded in mystery and leaves nurses on the front line wondering why their employer was allowed to break the law. It is important to note that AB 2899 does not establish any new violations, penalties or enforcements. It merely requires the dissemination of information about the current process regarding violations moreover is limited in scope to situations where the substantiated violation and does not impose any requirements in case there is no substantiated violation. Thank you.

Thank you. Please go ahead.

Good afternoon. My name is Diane Smith. I'm a registered nurse and a charge nurse at Kern Medical in the mother-baby unit. I've worked there for 21 years. I'm so proud of the work we do providing care to high-risk obstetric patients from all over the Central Valley. Short staffing puts our mothers and newborns at increased risk of serious but preventable complications. In spite of complaints being filed, we are continuously expected to work out of ratio. We're not getting the solutions our patients need.

I've submitted two separate complaints with CDHP recently. The first was when two patients didn't get the minimum two-hour recovery period required after their c-sections because of short staffing and labor and delivery. Each had postpartum hemorrhaging less than 1 hour after being transferred to our unit. I filed the second complaint after we had to admit a post-delivery and recovery mother and baby couplet when we weren't staffed to care for them in the first place.

We were out of ratio for over half the unit, half the shift on that unit, and while having to admit even more post-delivery couplet patients from labor and delivery. In spite of the substantiated complaints about short staffing, management has only provided temporary band-aids that have resulted in poor patient outcomes. We must ensure they're following through when complaints are filed.

AB 2899 will make sure that both the person filing the complaint and their union will know the steps management should be taking to come into compliance with the law. This issue just doesn't affect our licensed and unlicensed staff. It truly harms the vulnerable population we serve. I'm here today on their behalf. Please help us make sure hospitals put the safety in the lives of our patients in the forefront of care and pass AB 2899. Thank you.

Thank you. Are there any other witnesses in support? And if there are any primary witnesses in opposition, please come forward to the.

Madam Chair, Members, Sara Flocks, California Labor Federation, in support. Thank you.

Hi, Madam Chair. Janice O'Malley, AFSCME California in support.

Anna Palacio, registered nurse at Kern Medical Hospital representing SEIU Local 521 in support.

Matt Lege, on behalf of SCIU California, in support.

Thank you. Any witnesses in opposition? Seeing none, I will bring it back to Committee for comment or question.

Thank you for bringing this bill forward. I unfortunately have a very good friend who is in the nursing profession and has walked away from the hospital she's working at and now working for school district so she can make sure she can do the thing that she loves the most is taking care of people and not being ridiculed and put down in a toxic environment. So thank you for bringing this bill forward.

Mr. Gabriel, you may close.

Thank you very much for that Assemblymember. And I will tell you, part of the reason that I've arrived at this issue worked on is my mom worked for many years as a nurse in labor and delivery and I know stories of her working 40 years ago. She would share with me when she felt that their hospital was so out of ratio that she was worried that she would put patient safety at risk if she stopped to go to the bathroom during a 12-hour shift.

So this has been an issue that has persisted for a long time. We're fortunate to have some good laws on the books here in the State of California, but we all know that good laws without enforcement don't make a difference. And that's what this bill is about.

It's about moving forward on that enforcement piece so that these folks who all of us have acknowledged are our healthcare heroes and did heroes work during the pandemic, can have a seat at the table, and can have a safe work environment, as can our patients. So with that respectfully request an aye vote.

Thank you so much for bringing this bill forward Mr. Gabriel. I have a nurse, Auntie myself, 23 years, OBGYN Nurse, and it's so important that we continue to protect our frontline healthcare providers. So thank you for this bill and for the package of bills that you were able to bring forward to this Committee. And I know you have a lot of important work to do. So thank you for your time.

Thank you very much. Appreciate it.

We will move on now to Mr. Villapudua's bill. AB 2701, item number 23.

Thank you, Madam Chair and Members. AB 2701 will expand California Medi Cal Dental benefits to include a second cleaning and exam for adults age 21 plus. Currently, current Medi Cal Den dental benefits cover two cleaning and exams per year for those up to the age of 21. However, once an individual is age 21 plus, their Medi Cal benefits dwindles to only cover one cleaning and exam per year. While California Medi Cal Dental benefits includes more than substantial and comprehensive dental treatment then the other states.

The limitations of only one cleaning annual is where California falls behind. With a second cleaning of an exam, dentists can detect oral health complications, prevent tooth loss, and even detect early heart problems and several reports suggest poor dental health is linked to diabetes, dementia and other diseases. With me today to testify and to answer any questions is Jessica Moran with the California Dental Association.

Please go ahead, you'll have two minutes.

Good afternoon, Chair and Members. Jessica Moran with the California Dental Association appreciate the author for bringing up this bill. Despite recent investments and improvements in the Medi Cal program such as Prop. 56, tobacco tax investments, and Cal AIM, as well as administrative fixes, there are still holes in the benefits that are covered by Medi Cal. AB 2701 would establish an equitable standard of care for adults who are enrolled in Medi Cal to receive their two visits and cleanings a year.

Prevention is key, as the author mentioned in avoiding dental disease and comorbidities down the line. Respectfully ask your aye vote today.

Other witnesses in support.

Vanessa Cajina on behalf of the California Pan Ethnic Health Network in support.

Jennifer Tannehill with Erin Reed and associates on behalf of the California Dental Hygienists in support.

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

Linda Nguy with Western Center on Law and Poverty in support.

Any witnesses in opposition? Seeing none, I will bring it back to Committee for comment or question. I have one question, just clarification, Mister Villapudua, can you share what the industry standard right now is? Or maybe for CDA, industry standard right now is for dental plans for the amount of well-care visits.

So for commercial patients, it's typically two cleanings per year. The ADA recommends, you know, getting clean and cleanings as often as possible, but for commercial pay, it is two cleanings a year. And I would also just add that 27 other states have their Medicaid recipients receive two cleanings a year. So this is 11 of the issue, one of the areas that California falls short in compared to other states.

And we're still kind of recognizing that even though there's a standard of wanting two cleanings per year, we still have an issue with Medi Cal being accepted for many dentists as well. So separate issue, but related for sure in terms of overall access. Well, thank you for that. With that, Mr. Villapudua, you can close.

Yeah, I'd like to just say that, you know, when this bill first came forward, I was, I even called my dentist just to, just to kind of find out what usual happens, like how many, how many cleans do we have a year? But then I dug deeper to realize that it is very true that a lot of diseases, if you're not, if we're not taking care of our hygiene, we're going to be able to prevent a lot of different diseases, especially at our hospital.

So this bill really makes a lot of sense. So asking for your aye vote today.

Thank you. And when we are able to establish quorum, we will certainly move forward. Thank you so much for the presentation. We will move on now to, while we are waiting for the last non-Committee Member's presentation, we will go with our majority leader, Cecilia Aguiar-Curry.

This is item 11, AB 2237.

Thank you, Ms. Chair and Members. First, I would like to thank the Committee staff for their continued work with our office and accept the Committee amendments. We know this will be an ongoing conversation with all stakeholders so that our most vulnerable youth come first. Today, californian youth are facing a mental health crisis, and we've heard that numerous times today.

Since 2017, rates of anxiety and depression among California's children have shot up 70% and one-third of California's adolescents experience serious psychological distress between 2019 and 21, including a 20% increase in adolescent suicide rates. Many families struggle to find affordable mental health care for their children. Specialty mental health services provided by county mental health plans provide a key lifeline for over 243,000 youth across California.

In order to receive these services, youth under 21 must have a condition placing them at high risk for a mental health disorder, have significant impairment and mental health disorder, or have significant trauma like sexual assault. However, when youth move from county to county, their mental health care is halted while they reestablish eligibility. When they're moving from county to county. This results in gaps in mental health care that can burden families and risk minors entering the foster care system.

This bill supports families by streamlining eligibility across county lines for high-risk youth who qualify for specialty mental health services. AB 2237 would require that DHCS issue guidance to support counties, coordinate and expediate the transfer of specialty mental health services from one county to another. This bill will help empower families who don't know how to navigate complicated social services so that their youth'sz continuity of care is preserved.

Today, I have with me Courtnie Thomas, senior manager of operations at the California Council of Community Behavioral Health Agencies. Welcome.

Please go ahead.

Thank you, Chair, Members, and staff of the Committee. As mentioned, I'm Courtnie Thomas. I'm senior manager of operations and on behalf of the California Council of Community Behavioral Health Agency, CBHA. I thank you for hearing AB 2237 during this Committee. So CBHA is a statewide association of mental health and substance use disorder community agencies serving over 1 million Californians across the lifespan. It's common to see many families in California rely on the county's Specialty Mental Health Services, or SMHS.

It's a key lifeline for Medi Cal and officials across the state. And in the fiscal year of 2020 to 2021, the service system provided services to over 243,000 youth under the age of 21. 73% of those were black indigenous people of color. However, when children youth under the age of 21, as mentioned, move from county to county, they must start fresh, resulting in gaps in mental health care that can burden families and risk minors entering the foster care system.

This bill supports families by streamlining eligibility across county lines for high-risk youth who qualify for specialty mental health services. As mentioned, California's foster youth are facing a mental health crisis. Between 2019 and 2021, there was a staggering 20% increase in youth suicide. AB 2237 keeps critical mental health coverage intact so that youth can move and transition where mental health care is most critical.

Specifically, as mentioned, when a minor receiving specialty mental health services in one county moves to a new county, the new county must provide continued specialty mental health services while they conduct the required investigation and transfer process, as this bill preserves county's ability to conduct appropriate reviews to meet changing mental health needs and conditions, while also ensuring, as mentioned, the continuity of care for youth. Thank you again, Chair, Members and staff, for allowing us to express the need of this bill, and CBHA is the proud sponsor. Thank you.

Thank you. Are you going to speak as well? You're just here for technical support. Thank you. Any other witnesses in support?

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

Thank you. Any witnesses in opposition? Seeing none, I'll bring it back to the Committee and I'll just start by saying huge gratitude to the author for bringing forward this bill. I've worked with many youth over years and one of the biggest struggles that they have is to continue to have consistency of care as they get shuttled around throughout our either family regulation lives system or whatever is happening with them personally.

So I'm very thankful for this bill and believe that it will provide tremendous amount of support to many youth in California. And thank you to our sponsors as well. With that, we actually do have quorum now, so we will first secretary take the role. Would you like to close first majority leader?

I would. First of all, this is a really important bill and it came to my attention by my fellow and when we are being told that a child moves from county to county and loses the continuous support that they need, I thought I was shocked that how much time it takes and how someone could fall through the cracks. So I'm honored today to present this bill to you.

You know, it takes, it's an important first step for maintaining continuity of care for our most vulnerable youth and helps relieve burdens on families and caregivers. And I hope you will all support this bill. It's not only is it personal, it's just, it's the right thing to do. So thank you very much.

Thank you. With that to establish quorum, Secretary can you call the roll?

[Roll Call]

We have established quorum, so this is item 11, AB 2237. Do I have a motion? The motion would be do pass as amended to Human Services.

Second.

I think I heard Mr. Rodriguez and Ms. Sanchez seconded. Secretary, please call the roll.

[Roll Call]

Nine to zero. That motion passes. Bill is out.

Thank you very much.

Thank you. We are going to now move forward with voting on the bills that we have already heard since we have quorum. And then we'll move back to hearing additional bills. So with that, we will start with our consent calendar. Motioned by Waldron. Seconded by Rodriguez. Please call the roll.

That measures out 9-0. Item number 12, AB 2258 Motion is do pass to appropriations by Waldron. Seconded by Aguiar-Curry. Please call the roll.

[Roll Call]

9-0. The consent calendar is out. We'll move now to item number two, AB 1970. That's do passed as amends.

Second.

Motion by agia Curry. Seconded by Joan Sawyer. Please call roll. It's do pass to appropriations.

[Roll Call]

That measures out 9-0. We'll move on to item number three. AB 1977, Ta motion is do pass to appropriations moved by Aguiar-Curry. Seconded by Sanchez. Call the roll.

[Roll Call]

That measure carries 10-0. It's out. Item number 10, AB 2169 the motion would be do pass to appropriations by Aguiar-Curry. Seconded by Waldron.

[Roll Call]

[Roll Call]

That measure passes 9-0. We'll move on to item 13, AB 2297 Friedman motion it would be do pass as amends to judiciary. Moved by Aguiar-Curry. Can I have a second? Second by John Sawyer. Please call the roll.

[Roll Call]

9-1. That motions out. That measures out, we'll move on to 18, AB 2428 do pass to appropriations. Can I entertain a motion by Aguiar-Curry? Seconded by Haney. Please move forward with the role.

[Roll Call]

10-0. That motion that measures out item number 20 AB 2550 motion is do pass to business and professions. Aguiar-Curry moved, Sanchez seconds. Please call the roll.

[Roll Call]

10-0. That measures out item number 22 AB 2700 Gabriel, the motion is do pass as amends to emergency management. Can I have a motion? Aguiar-Curry seconded by Rodriguez. Please call the roll.

[Roll Call]

10-0. That measures out AB 2701, item number 23 Villapudua motion is due past two appropriations. Is there a motion? Aguiar-Curry. Seconded by Haney. Please call the roll.

[Roll Call]

That measures out 11-0. Item number 24 AB 2749 Wood do pass as amended to appropriations. Aguiar moves Aguiar-Curry moves seconded by second John Sawyer. Please call the roll.

[Roll Call]

That measures out 10-0. Item number 26, AB 2899 Gabriel. The motion is do passes amended to appropriations. Can I have a motion? Item number 26 moved by Aguiar-Curry. Thank you, Doctor Weber seconded. Please call the roll.

[Roll call]

That measures out 10-0. We will move on. This bill? Yes, vote change Sanchez.

To support Sanchez from not voting to aye. That's 11-0.

That's 11-0. That measures out. We will move to item number 28, AB 3030. Do pass as amended to privacy and consumer protection. Moved by Aguiar-Curry. Seconded by Waldron. Please call the roll.

[Roll Call]

13-0. That measures out as well. Item number 29, AB 3129 would this is do pass as amended to judiciary. And just to note this, do I have a motion moved by Aguiar-Curry, seconded by Arambula? Please call the roll.

[Roll Call]

That measures out 10-3. We'll move on to item number 31, AB 3218. The motion is do pass to judiciary. Doctor Wood, do I have a motion moved by Aguiar-Curry, seconded by Doctor Weber? Please call the roll.

[Roll call]

And as a point of personal privilege, I would like to note that AB 3218, by Doctor Wood marks likely the last measure that he will bring before the Assembly Health Committee, a Committee that he shepherded and stewarded as a leader for nine years.

And we're incredibly thankful to Doctor Wood for his service over time and certainly unflavored tobacco list Bill AB 3218 will go down as a point in our history. Thank you so much. That measure is out 10-0. Doctor Wood.

We will now resume with our bills on file. Moving to Dr. Weber. She's ready. Item Number Six: AB 2058.

Good afternoon, Chair and Members. I'm here to present AB 2058, a bill on medical devices. Medical devices are the technologies that diagnose, treat, and improve a person's health and well-being, and include both low and high risk medical devices. These products may vary from tongue depressors, bedpans, medical thermometers, to insulin pumps and complex pacemakers. As a physician, I understand the importance of these advancements in science and technology.

Advancements in this medical technology have resulted in significant positive impacts for patients and the health care industry as a whole. It has increased life expectancy for Americans by five years and reduced the duration of hospital stays by 38 percent from ten days to 6.2 days. Still, these technologies and devices are not without flaw. The final California Reparations Task Force, released in June, highlighted the disparities that exist within the use of these medical devices.

But this disparity has also been highlighted in studies and other reports in a variety of medical and non-medical publications for over decades, and have significantly increased since the Covid-19 pandemic. Let's take the pulse oximeter, for example. This is a device that we use to determine the oxygen level in patients since 1974. This FDA-approved device is as common in the health care setting as a blood pressure cuff.

However, studies since as early as 1976, before I was even born, have demonstrated that it is less accurate among patients with darker skin and therefore, result in adverse health outcomes for those patients. Many clinical studies in adults and children have shown a clear difference in pulse ox readings versus the actual blood saturation levels, generally showing falsely higher readings in people of racial and ethnic minorities.

In fact, a retrospective study published in JAMA of July of 22 confirmed that Asian, Black, and Hispanic patients were less likely to receive the supplemental oxygen that they needed because of their falsely elevated pulse ox readings. This resulted in increased morbidity, and this is because we in the medical profession utilize these medical devices to create medical algorithms for treatment and management of patients.

So, for example, if a institution determines that your oxygen saturation is less than 92 percent, then they develop an algorithm that states that you should start on supplemental oxygen. But if the device that is being used to test your oxygen level gives you a falsely elevated reading of 95 percent, but in actuality you're 90 percent, then you're not receiving the treatment and the care that you should.

And unfortunately, the pulse ox monitor is not the only device that has been shown to not be effective in persons of color. A recent study by Emory University found that forehead thermometers were significantly less accurate, 26 percent lower than oral thermometers, in detecting fevers for Black patients. And how many of us now go and see our doctor or to the hospital and have our temperatures taken on our forehead and no longer orally?

These types of inaccuracies can lead to delays in diagnosis or drug administration and could possibly have fatal implications. Disparity in effectiveness has many times been attributed to the lack of testing on diverse populations before a device is placed on the market.

In December of 2022, President Biden signed into law, the Consolidated Appropriations Act of 2023, which included requirement that clinical trial sponsors submit to the Secretary of the U.S. Department of Health and Human Services a quote, 'diversity action plan' for most medical device studies, but still, more must be done now.

AB 2058 requires a medical device manufacturer to include a disclosure on the device or its packaged material on the known limitations on the effectiveness of the device due to certain characteristics of the patient, including but not limited to age, color, gender, or race. While there are federal efforts to address diversity in the development of devices, consumers, including physicians and health care facilities, still need to be informed of potential limitations of medical devices that may arise even if you do have diverse clinical trials. And with that, I thank you, and respectfully ask for your aye vote on AB 2058.

Move the bill.

Moved by Aguiar-Curry; seconded by Arambula. Thank you. Are there any witnesses--other witnesses in support? Any witnesses in opposition?

Madam Chair and Members, John Wenger, on behalf of the Advanced Medical Technology Association. We're the national trade association for medical device industry. Don't have a formal position right now. Want to thank the author for the continued conversations. We've been discussing a lot around this issue and trying to kind of figure out what the right structure would be.

I think under the current structure of the bill, we do have quite a few concerns both around costs going through the FDA process for changing--even labeling can have pretty significant costs. We also have some concerns around the liability, if there is some sort of, if there is some determination later on that the device has some sort of fault, than the liability that gets placed on the manufacturer, we have some concerns around that.

We also have a few concerns around just potential unintended consequences of adding disclaimers and having contraindications just to legally protect yourself, but then there can be some unintended consequences there that limit the use of products in the future, and we've actually had a couple instances like that with the FDA and we can talk through kind of those issues at a later date, but currently do have some pretty significant concerns with the structure of the bill, but look forward to continuing the conversations. Thank you.

Thank you, Madam Chair and Members. David Gonzalez, on behalf of the California Life Sciences. We'd like to associate ourselves with the comments of Mr. Wenger. I want to continue to work with Dr. Weber on this important issue. I want to thank her for her kind comments about the industry at the beginning of her opening. So thank you, and we look forward to the continued conversations.

Dr. Weber, would you--I'll bring it back to the Committee now for any comment. Dr. Weber, I want to note that this is a part of--as you highlighted--a part of the California Reparations Task Force report findings, and I'm thankful that we have an opportunity to address the inadequacy currently of medical devices for patients with darker skin, darker melanin, and we know that that inability will increase adverse health outcomes for patients right now.

So we appreciate that you are moving forward with this bill, and we'll continue to work with the opposition as stated to figure out a good place for the bill to land ultimately. With that, please close.

Well, I want to thank the Committee staff for the amazing analysis of this bill, and you know, this is one of the things that came out of the California Reparations Task Force, but as stated in my opening statement, this is not something that just impacts Black Americans. It has been shown to negatively disproportionately impact Asians, Hispanics, you know, anyone with melanated color.

And the issue is that as we move into--more into a society that relies more on these devices and we create algorithms on how we're going to treat patients based on them, if it's flawed from the beginning, then everything downstream will be flawed. So we'll continue to work with the opposition. Very much looking forward to getting actual language that would make them comfortable.

But at the end of the day, we cannot allow our openness and the need for better technology in the future to continue to allow for these medical disparities to exist here in our country. So with that, I respectfully ask for your aye vote on AB 2058. Thank you.

Thank you, Dr. Weber. Do I have a motion? Oh, we do. Okay. The motion is 'do pass to Appropriations.' Please call the roll.

[Roll Call].

That measures out 11-0. We have one author who is not a Committee Member. So we are going to give them time to work their way over from another Committee that they are on. So we'll move forward with AB 2365. Haney, item number 15.

Thank you, Madam Chair. I'll keep this relatively short and sweet. This bill has no opposition and a lot of support it will protect California consumers by establishing health and safety regulations for kratom products sold in the state.

Kratom, if you're not familiar with it, is a tree in the coffee family native to Southeast Asia. In low doses, kratom produces a beneficial stimulant effect like increased energy, alertness, concentration, physical energy and productivity.

But in high doses, kratom causes a sedative effect and other negative symptoms like nausea, increased heart rate, insomnia, and some psychotic symptoms like hallucinations and confusion.

Additionally, consistent kratom use can lead to dependency, and some people do use kratom as a less dangerous replacement for opioids and opioid use disorder. In the absence of federal action, many states have decided to regulate kratom so that only safe and unadulterated products are being sold to consumers.

However, nearly 25% of all kratom sales in the United States are in California. And with the increased demand for kratom products and a lack of regulations, some manufacturers have irresponsibly created stronger and more potent kratom concentrates to put into their products.

To prevent unadulterated high potency products from hurting California consumers, AB 2365 will enact robust regulations for kratom products. It will ensure manufacturers are only producing safe products and that consumer is able to maintain access to the benefits of safe and regulated kratom.

With me here today to testify is David Quintana, on behalf of the Global Kratom coalition. And we are happy to also answer any technical questions.

Thank you. You'll have two minutes. Moved by Rodriguez, seconded by. Is that a no by Doctor Arambula?

Trying to cut you off, I know.

Good afternoon. Chairwoman David Quintana here on behalf of the Global Kratom coalition, to speak in support of AB 2365. This bill brings well structured, common sense regulation to the burgeoning kratom industry in California, and it does so in three ways.

First, it defines kratom and kratom products and establishes rigorous packaging and labeling standards. We feel this information is essential to empower consumers to make safe and informed decisions. Secondly, it sets age restrictions for purchase.

Limiting kratom products to adults safeguards public health and prevents potential misuse with underage populations. Third, it mandates registration and compliance with testing requirements from kratom processors.

Registration and testing kratom products will root out the bad players in the industry and help ensure product safety and quality that will reduce the risk of exposure to harmful contaminants or adulterants. The regulation and compliance called for in this bill are currently non existent in California, but are essential for protecting consumers from unsafe products while holding the industry accountable.

As 25% of the kratom market in California, this bill ensures that our state will have access to safe, quality kratom products, leading the way in promoting public health and supporting a thriving kratom industry. Thank you.

Any other witnesses in support? Any witnesses in opposition? I'll bring it back to the Committee. Any comments, questions? Mister Haney, you may close.

Thank you. Respectfully ask your aye vote.

Thank you. The motion is do pass to environmental safety. We already have a motion in a second. Please call the roll.

[Roll Call]

That measures out 12-0. We're going to move on now to Doctor Arambula. He has three bills. Four.

We may, Doctor Arambula, take an instrumental break so to speak. If our Non-Committee author approaches, we will start with item number seven. AB 2110. Moved by Santiago, seconded by Rodriguez. Please go ahead when you're ready, Dr. Arambula.

Thank you, Madam Chair and Members. I want to start by thanking the Committee for their Diligent work on this bill. I acknowledge the concerns that the Committee has laid out in their analysis and am committed to engaging with the Department of Healthcare Services and other stakeholders as this bill moves forward. All Californians should have access to trauma informed screenings by health care providers that they trust.

Because community health workers and doulas are the trusted providers for so many, AB 2110 authorizes them to receive medical reimbursement for conducting ACEs screenings.

ACEs, or adverse childhood experiences, are traumatic childhood experiences like abuse, neglect or exposure to violence, mental illness, divorce, substance abuse, or criminal activity at home. Individuals with multiple ACEs are at risk of toxic stress physiology and often face significantly increased risk for the leading causes of death, including heart disease, stroke, cancer, diabetes, and more.

While not eligible for medical reimbursement, community health workers and doulas are uniquely positioned to conduct ACEs screenings because they are seen as highly trusted providers who emphasize the two generation approach.

This is crucial because aces can follow a pattern of intergenerational trauma where children or parents with ACEs can be at greater risk themselves. Testifying in support of AB 2110 Winola Eleganju with the Fresno Community Health Improvement Project and Libya Alejo with Cultiva La Salud.

Please go ahead. You'll each have two minutes.

Greetings, Committee. My name is Winola Eleganju. I am a certified community health worker with Fresno Community Health Improvement Partnership. I am humbly requesting your support of AB 2110 as it currently stands as we want to acknowledge the work of CHWs and doulas when it comes to adverse childhood experiences best known as ACE screenings.

As many people know, ACE can lead to toxic stress within a child as abuse, neglect, substance abuse, and other traumatic experiences growing up can all lead to trauma that stays with them.

Past childhood CHWs like myself are often positioned to be pillars of support in the community as we find ourselves supporting families whom we build relationships, support and care agencies such as the Black Wellness Prosperity Center. Co-sponsors of this bill also agree with this extension, too.

Through this, we often understand each other as some of them may be from the same background, others may be from the same neighborhood. CHWs and doulas are often with families that find themselves looking for support, care and understanding, as many would refute sharing their traumas outside of their community.

Because of this, CHWs and doulas are given the unique experience and opportunity to complete ACEs screenings and in turn, support families who wouldn't normally come forward expressing their needs to their medical providers.

I hope this encourages you to support AB 2110 as we want to make sure that doulas and CHWs are recognized for their work in aces and their community and expert care opportunities for all in the name of community healthcare.

By having the opportunity to receive aces awareness training, CHWs and Doulas will be better equipped to support families and migrating the adverse effects of ACEs, which will ultimately lead to better health outcomes for children, families and our community.

As a CHW myself, I have seen firsthand the positive impact that this type of support can have on families. I hope you will consider supporting AB 2110 as it recognizes the important work that our CHWs and doulas do in our communities.

Thank you. Go ahead.

Hello. Good afternoon. My name is Libya Alejo and I am a community health worker for Cultiva La Salud. In my role as CHW, I have developed trusting relationships with the community by spending time with them and establishing report. Because of this, I have become a trusted source of information and support for the community. This would make the screening more comfortable for the community members that we serve.

In my role as a CHW, I have established connections with other community based organizations to facilitate referrals and collaborations to ensure our participants receive the services they require. As a CHW, I provide cultural sensitive care to my participants in order to ensure as they are comfortable and understood.

As many communities in the Central Valley speak multiple languages and dialects, language capacity is extremely important.

As a result of embracing diversity and acknowledging cultural differences, I have created a safe space where my participants can express their concerns and experiences. I have shared also my personal life experiences similar to those to my participants, bringing unique perspectives, combining a deep understanding to the needs for our communities.

Everyone should be able to receive trauma informed aces screenings from healthcare providers they trust. Many community members often turn to CHWs and doulas for this reason. This will give the community reserve the opportunity to get faster services regarding aces, this is why I support AB 2110. Thank you.

Thank you. Other witnesses in support?

Dylan Elliott on behalf of the California State Association of Psychiatrists in support, thank you.

Linda Wei with Western Center on Law and Poverty in support

Nora Lynn with Children Now in support

Kathy Mossberg, Local Health Plans of California in support.

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

Thank you. Any witnesses in opposition? Seeing none, I'll bring it back to the Committee for comment or question. I believe we already have a motion and a second. I will say I thank you Doctor Arambula for working with Committee staff on this one with Lisa.

I know that there was some back and forth just to kind of understand the issue of recognizing the critical importance of community health workers, promotors and representatives and also recognizing the requirement to have that happen under a clinical setting and have the respective billing practices mirror that.

So I know that you'll keep on working on that issue. And with that, Chairs recommending an aye. Please call the roll.

Thank you for the opportunity to present. I respectfully ask for an aye vote.

Thank you.

[Roll Call] And the motion was due past two appropriations.

14-0 that measures out and we will rotate in your next set of witnesses. Doctor Arambula for item number nine, AB 2161.

Thank you, Madam Chair and Members. I first want to thank the Committee for your work and will be taking the Committee amendments today. It is essential that the first episode psychosis or early psychosis be identified before individuals experience harm. Because the current landscape of first episode psychosis intervention is fragmented and that the standards of practice can vary from county to county.

AB 2161 will direct the Mental Health Services Oversight and Accountability Commission to create a strategic plan to understand psychosis and to document the physical impact of unaddressed psychosis. This Bill will direct the Department of Healthcare Services to partner with the UC to develop a plan to establish the Center of Mental Health Wellness and Innovations, which will promote evidence based practices to improve behavioral health services and to bring transformative change in behavioral health service delivery.

Moreover, early psychosis occurs when a person first experiences psychological disturbances that manifest as disturbed thoughts, perceptions, or having trouble in distinguishing reality from illusion. Untreated psychosis may result in impaired judgment, putting individuals at risk of engaging in dangerous behaviors such as self harm, substance abuse, and suicide. In the United States, approximately 100,000 young people experience episodes of psychosis every year, with an average onset in the late teens to mid twenties.

Through coordinated specialty care, medical professionals can take steps to develop specialized treatment plans for their patients. Additionally, in California, there are 30 early psychosis programs throughout 24 of the 58 counties in the state to treat the estimated 100,000 young people who experience psychosis each year, the state needs an estimated 300 additional psychosis programs to meet the needs in communities, especially in our rural and remote areas.

This Bill will help us to move upstream and ultimately to reduce long term costs in our public hospitals and our prisons. The state can take a lead role in developing strategies to provide resources on early psychosis for our most vulnerable populations. In support of AB 2161 today, our two witnesses, Bonnie Hoets, who will share her lived experience story, and Doctor Tara Niendam, Executive Director of the UC Davis Early Psychosis Programs.

Doctor Arambula, you have a motion from Santiago and seconded by Rodriguez. Witnesses, you'll have up to two minutes.

Good afternoon, Chair Bonta and Members of the Committee. My name is Bonnie Hoets, and I'm the mother of a daughter living with psychosis. I'm also an advocate for early intervention and have supported many other families going through this with their children. I greatly appreciate the opportunity to be here, and I want to thank Assemblymember Arambula for authoring 2161.

In my view, it's a lifeline for parents desperate to save their children from this illness. I know that desperation. Back in 2008, my 15 year old daughter Rachel was accepted into the UC Davis Early Intervention Program that was able to roll back the worst of her symptoms and save her life. It was extremely hard to find the care she needed back then. It took almost two years of searching, precious years as the window for early intervention closed.

Desperate years of feeling helpless, watching the daughter I knew slip away. Once loving, high achieving and focused, excited to be in high school and as a freshman already looking forward to college, Rachel became withdrawn, disorganized, and aggressive. She abandoned all her interests and began failing classes. By the time we found care, she was suicidal. You would think that such a devastating illness, one that attacks our children's minds and derails their potential at a time when they are just starting to grow into it.

You would think that such an illness would warrant an all hands on deck approach. But that's not what's happening. This care is still, still, all these years later, largely not available. Instead, it's a patchwork quilt full of holes that children and their families are falling through. We can do better. So I respectfully request your aye vote on AB 2161. Thank you.

Thank you.

Thank you so much, Madam Chair and Committee, for hearing this today. And thank you to Assemblymember Arambula for supporting this work. My name is Tara Niendam. I'm a Child Clinical Psychologist, Professor in the Department of Psychiatry at UC Davis, and the Executive Director of our Early Psychosis programs. I also have the privilege of serving as the Director for the EPI-CAL program here in California. Which was developed as a partnership between the Oversight and Accountability Commission, now the Department of Health Care Services, in multiple California counties.

Since 2018, we've been building a network of early psychosis programs across the State of California with the goal of harmonizing data collection to, as Assemblymember Arambula said, understand exactly what's going on in our communities and how to do better, as well as to provide training and technical assistance to those communities who want to build programs like ours. Right now, we are currently working with 42 of the 58 counties across the state to enhance EP programming, but we're just beginning.

As the Assemblymember said, we need more than 300 programs to serve the need in our state, and we're not there yet. We have about a 10th of that, and our network is fragile. We are built with piecemeal funds and one time funds. This Bill seeks to fix that problem.