Assembly Standing Committee on Health

Good afternoon. Welcome to the Assembly Health Committee hearing on April 16. Before we begin, I would like to make a statement on providing testimony at this hearing. All witnesses will be testifying in person. We allow two main witnesses for a maximum of two minutes each instead of three minutes. Additionally, testimony will also be in person and limited to name, position and organization. If you are present, we have the consent calendar today of several items. The following bills are proposed for consent for today's hearing. Any Member of the Committee may remove a Bill from consent. [Consent Calendar]

We will start our hearing as a Subcommitee and to be able to ensure we have typically go in file item order, but we are going to allow for Doctor Jackson to present now. Doctor Jackson file item one. AB 1799. Please proceed whenever you're ready, Doctor Jackson.

Mic's okay. Thank you. Thank you very much. Looking forward to your questions, except Mister Sawyer. Do not want any questions from him. AB 1799 seeks to require the State Public Health officer to include the impact of racism on public health in their annual written report to the Governor and the Legislature on the state of public health in California.

Current law requires the state public health officer to submit a written report to the Governor and the Legislature on the State of public health in California and present an annual update to relevant budget committees.

Unfortunately, this report currently does not address or capture the impact of racism on public health, even though public health professionals and associations have already declared that racism is a public health issue and thus leaves a critical factor in public health outcomes off the table, further exacerbating the harm of leaving racism out of public health conversations. Data has shown that historically redlined census tracts have significantly higher rates of emergency department visits due to asthma suggesting that this discriminatory practice might be contributing to racial and ethnic asthma health disparities.

By including the impact racism has on public health in this report, AB 1799 will ensure a comprehensive view on key issues and the potential causes of the issues and can also potentially limit effective policy solutions to address racial disparities in health outcomes. I respectfully ask for an aye vote.

Thank you, Doctor Jackson. Seeing are there any witnesses in support? Any witnesses in opposition? Seeing none. We'll bring it back to Committee for comment or questions.

Just a comment.

Mister Jones-Sawyer.

Out of order.

I want to thank you for bringing this forward. As we all know that there's an implicit bias, not only in the medical profession, but it has ramifications that are even experienced in the algorithms that are done by the hospitals and other medical facilities. My case, for example, they prescribed all sorts of different diabetes medicines when in fact, an African American doctor, or actually nurse, told me that I needed to change my diet and lose some weight, which dramatically helped me.

Instead of looking at an African American such and such an age, weighing such amount that a certain algorithm, you had to give him pills and put them on different shots. The real solution was just having a healthy diet. And a lot of times not looking at me by what I look like in my race, but looking at me as the person and coming up with the proper diagnosis is the best way. So I applaud you for doing this.

It will be very helpful to be able to ascertain that information as we move forward.

Thank you.

Mister Jackson. I'll bring it back to myself. Thank you so much for bringing this Bill forward today. This Bill strengthens our annual State of the Public Health Report, which already mentions racial disparities by requiring DPH to discuss the impact of racism on the information in its reports. By having the report expand on what causes racial disparities, namely the historical legacies of structural racism, this Bill will help the Legislature make more informed policy decisions on public health policies in the years to come.

Would you like to close?

I respectfully ask for an aye vote.

Thank you so much. And when it is time for us to be able to have that with. Once we establish quorum, we will move forward with this Bill. Thank you. In the room right now, ready to test, ready to present their bills, are Miss Pellerin. Miss Pellerin, please come forward.

Thank you, Madam Chair. I'll begin with AB 2866.

Item number 22.

So thank you, Madam Chair and Members, for the opportunity to present AB 2866. In my district, on Monday, October 2, 2023, one-year-old Peyton Cobb and 18-month-old Lillian Hannon lost their lives in a horrific event. These children were at a licensed home daycare located in San Jose when three toddlers accessed the swimming pool located on the premises unsupervised after being transported to the hospital in critical condition, two of the children were pronounced dead.

I introduced AB 2866 to try and prevent this tragedy from ever happening again. The daycare had met the current requirements for pool safety. The pool was deemed safe under current safety standards by California code requirement. The current pool safety code regulations are outdated, having been enacted in 1996. The Swimming Pool Safety Act requires a two-stage safety system to be installed in a home pool.

However, the Swimming Pool Safety Act had left an exemption for any facility which was regulated by the State Department of Social Services, which includes daycare facilities, group homes, and senior facilities. The State Department of Social Services only requires a fence to prevent an accidental drowning. The main issue arises when the potential hazards associated with a single safety mechanism, the ability for a single mechanism to be bypassed or a failure allows for a drowning hazard.

In the case of the daycare responsible for Lillian and Peyton, the homeowner the previous night had bypassed the gate and propped it open. This resulted in the gate being unable to serve the intended safety function. AB 2866 will create a multifaceted safety requirement to update the existing standards to allow for better drowning prevention standards. The Bill would require an updated safety requirement in addition to the fence that meet current standards, as well as either a pool cover or, or an alarm system.

This would create a two-step system that in the event of a failure, a secondary safety precaution will be able to prevent a drowning. Additionally, AB 2866 will create a requirement for a daily assessment log to document that pool and facilities are being secured by the two-step system in accordance with the law. Before the center opens, I believe with me to testify in support is Bryce Docherty with the American Academy of Pediatric.

Good afternoon, Madam Chair and Members. I'll be very brief. My name is Bryce Docherty on behalf of the American Academy of Pediatrics, California. The pediatricians in this state worked tirelessly two years ago with Senator Newman to retool the safety precautions for swimming pools, both public and private. And what the American Academy of Pediatrics has shown. Studies have shown that the safest way to protect children from drownings in pools and spas is a four-sided fence.

And that's what this Bill provides for, will be saving children in the State of California. And we strongly urge your support. Thank you.

Thank you. Are there any other witnesses in support? Any witnesses in support?

Thank you. Isabella Argueta with the Health Officers Association of California in support. Thank you.

Thank you. Are there any primary witnesses in opposition or other witnesses in opposition? Seeing none. I'll bring it back to the Committee for comment or questions. Thank you. We still do not have a quorum. So we are going to hold the Bill. I will say thank you for bringing this Bill forward.

It certainly requires, ensures that we require swimming pools and child care facilities regulated by DSS to be equipped with at least two safety features and requires daily inspection of the drowning prevention features. The increased safety standards will help keep our baby safe. With that.

Yes, I respectfully ask for your aye vote thank you when it's appropriate.

Thank you when appropriate. We'll move on now to item number 28, AB 3260. Also, Pellerin.

Thank you so much, Madam Chair and members. While my other bill, AB 3221, which is on consent, will improve top down enforcement of our state's health care laws by empowering the Department of Managed Health care to conduct enforcement more swiftly and more efficiently, this bill, AB 3260, will improve enforcement from the ground up by empowering patients to act on their own behalf. This bill addresses two problems.

First, the untimely resolution of claims and grievances by health plans and ensures and second, the lack of transparency and due process when consumers file regulatory complaints. To address the first concern, this bill will harmonize state law with federal law regarding the timeline for responding to claims for coverage and how claims for urgent conditions are treated. Importantly, a provider's designation of urgency will be binding on health plans, as is the case under federal law.

This closes a loophole whereby plans could second guess a claim's urgency and take up to 30 days to respond, rather than the 72 hours that's required for urgent requests. This bill also adds an important protection for those with degenerative conditions such as MS, prioritizing treatment that can minimize the loss of function instead of only those treatments that can restore the patient to full function. This ensures that patients receive the care they need, despite the fact that they will likely never return to full health care.

Delayed is care denied. Therefore, when health plans don't respond to requests for care in a timely manner, this bill provides that an internal grievance will automatically be initiated on a consumer's health. The bill then clarifies the timeline and notification requirements for grievances, again bringing state law into accordance with federal law.

If a health plan also fails to respond to a grievance within the required timelines, that grievance will automatically resolve in favor of the consumer, meaning that they can get care with the assurance that it will be covered. This provision follows the lead of New York and Massachusetts, which have equivalent provisions. Last year, DMHC found that our state's largest health plan had failed to resolve tens of thousands of grievances within the required time frame.

This bill provides a strong incentive for these disputes to be resolved in a timely manner, thereby reducing the likelihood that patient conditions worsen and subsequently require more intensive and costly treatment while they are stuck in limbo waiting for a health plan response. To address the second concern of the lack of transparency in due process and regulatory complaints, this bill prohibits ex part take communication between regulatory departments and any single party to a dispute, whether that be the health plan or the patient.

AB 3260 will improve transparency by permitting each party to see information provided to the departments in connection with a complaint. It will also improve due process rights by giving each party a reasonable opportunity to respond to the other side's assertions. Unfortunately, the current reality around complaints disadvantages consumers who see or hear little while their complaint is being reviewed. Health plans and insurers, on the other hand, enjoy frequent and regular communication with regulators. When health plans fail to follow the law, consumers suffer the consequences.

These costs fall particularly hard on underserved communities where patients cannot afford to pay for care out of pocket while they wait for health plans to respond to their claims to resolve their grievances. Taxpayers in our counties also bear a cost because many of these same patients will seek care from public services in the meantime.

To reiterate, while this bill will improve processes for all medical surgical issues, we are particularly eager to see the improvements it will make for those seeking treatment for behavioral health and substance use disorders, as these are some of the areas where patients struggle most to get timely and appropriate care. And with me to testify in support of AB 3260 is Doctor Karine Sacco, LMFT, and Benjamin Eichert, who's the assistant director of political community organizing for NUHW.

Thank you. You'll each have two minutes.

Good afternoon, Madam Chair and Committee Members. My name is Karine Sacco. I became a licensed marriage family therapist in 2006 and went on to earn my doctorate degree in clinical psychology in 2014 and became licensed as a psychologist in 2019. Thus, I'm a dual licensed mental health provider. I have over 20 years of experience, and I currently provide direct clinical services to California residents.

In my outpatient practice, there have been times in which my professional training and expertise lead me to determine that a client I'm serving needs a higher level of care than my practice can provide. In other words, outpatient therapy cannot provide the care needed to manage their severe mental health symptoms. And when this happens, transitioning to a higher level of care is urgent and medically necessary.

The significant emotional distress someone experiences at a time like this is only made worse when their health plan fails to authorize the request for a higher level of care, or worse, fails to respond to the referral at all. An AB 3260 would alleviate the undue hardship for consumers by requiring health plans to initiate a grievance on a consumer's behalf when they fail to respond within the time period and in the manner required by existing law.

I truly believe that there is no one better suited to determine whether a patient's condition is urgent than their therapist. California is facing a behavioral health crisis, and one of the first and most important steps in addressing this crisis is to improve access to timely and appropriate care for commercially insured consumers. I respectfully request your aye vote on AB 3260. Thank you.

Please go ahead.

Thank you chair and members, I'm Benjamin Eichert with the National Union of Healthcare Workers. We're the largest union of private sector behavioral health providers. We've sponsored two bills this year, and AB 3260 is designed to work in tandem with AB 3221 to improve health plan and disability insurer compliance with our state's patient protections. The process of securing coverage for medically necessary care and for resolving disagreements around denials can be understood as having three steps. The first step is a request for authorization.

If that request is denied, an internal grievance can be submitted, which is the second step, and if the internal grievance is denied, a regulatory complaint can be initiated. That's the third step, and it can include an independent medical review. AB 3260 resolves conflicts between state and federal law and clarifies parameters, including response and notification timelines for these steps, making them more enforceable by consumers.

When health plans and disability insurers fail to comply with the timelines and notification requirements for these steps, patients can get stuck in limbo waiting for responses and resolutions. As noted, the costs associated with this fall particularly hard on medically underserved communities. Last year, in a settlement with our state's largest health plan, DMHC found that over only a period of several months, the plan had failed to resolve thousands of grievances within the required time frames.

That same settlement agreement also noted that deficiencies have impacted the plan's ability to ensure adequate and timely access to behavioral health care services to its enrollees. Consumers deserve the tools necessary to ensure their own health plan complies with the law. That's why AB 3260 will provide fair and efficient consumer protections to address rampant health plan violations cited by regulators and noted at the October 2023 hearing of the Select Committee on Mental Health and Addiction.

Finally, we've received some questions about AB 3260, extending the time period from six to 12 months for consumers to file a request for an independent medical review. The spirit of this language is to protect those who have undergone a significant health crisis which can result in extreme mental, emotional, and financial hardship. We've seen that six months is just not enough time to resolve those challenges and and also navigate the IMR system. In closing, I respectfully ask for your aye vote.

Thank you. Are there any other witnesses in support? Please come forward. And as they're coming forward, if there are any primary witnesses in opposition, please come to the table.

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

Good afternoon. Whitney Francis with the Western Center on Law and Poverty, in support.

Cindy Young, vice president of the California Alliance for Retired Americans, in strong support.

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

Paul Yoder on behalf of the California State Association of Psychiatrists, a co sponsor in support. Thank you.

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

Erin Taylor, on behalf of the California Association of Marriage and Family Therapists, in support.

John Drebinger with the Steinberg Institute, in support. Thank you.

Jennifer Snyder with Capital Advocacy, on behalf of the California Life Sciences, in support.

Greg Pulsifer, Equality California, in support.

Symphoni Barbee, on behalf of Planned Parenthood Affiliates of California, in support.

Heidi Strunk, CEO of Mental Health America of California, in support.

Kelly Brooks, on behalf of the Board of Supervisors of Santa Clara County, in support.

George Brampthew, on behalf of the California Labor Federation, in support. Thank you.

Any witnesses in opposition? You'll have two minutes each.

Thank you. Good afternoon, Madam Chair, members of the committee. Jedd Hampton with California Association of Health Plans, representing 43 health plans that cover approximately 27 million Californians throughout the state. Regrettably, we are here in opposition to AB 3260. I would like to thank the author and her staff, as well as the committee staff, for engaging with us on this bill.

Specifically, we are concerned that this bill would allow health plan enrollees to self refer for services requiring utilization review in the same manner currently afforded to providers. Generally speaking, providers are responsible for submitting authorization requests to the health plan to ensure that a clinical evaluation has been conducted and that the requested service is appropriate for the enrollee. Additionally, providers maintain health records of the enrollee that are needed to make a medical necessity determination.

These factors are critical to ensure that the enrollee is receiving timely, clinically appropriate care that has been signed off by a provider, allowing enrollees to self refer for services, from our perspective, will only complicate and delay the existing authorization process. We are also concerned that this Bill would grant enrollees and the representatives access to unredacted copies of all correspondence concerning the enrollees grievance.

Notably, this provision does not require the DMHC to share with the health plan any information or rebuttals that come from the enrollee or the representative. Nor does the proposal allow for health plans to receive access to the same unredacted information afforded to the enrollee or their representative. Health plans would have no viable way to counter or abut potentially inaccurate or misleading information.

And additionally, this proposal does not take into account that there are existing avenues for enrollees or the representatives to access much of this information already, whether that be through a Public Records Act request, through a subpoena, or through the DMHC helpline, which is intended to help consumers process both grievances and IMRs moving forward.

So we do have some additional provisions of the bill that we'd like to work with the author's office on, but for now, we are regrettably opposed to AB 3260 and look forward to chatting further.

Thank you. Go ahead with your two minutes.

Steffanie Watkins, on behalf of the Association of California Life and Health Insurance Companies, we too are in opposition today. I guess Jedd and I have the same thing. We appreciate the time and commitment the author and sponsors have put towards the bill. We do have some significant concerns, as outlined by my colleague, specifically around the self referral for patients.

I think if you look at that, and the totality of our healthcare system really does dismantle that relationship and direct relationship between physicians and patients, and the necessity for that to be something that the patient looks to the doctor and the provider to assist them as they look to their healthcare needs. Additionally, we do have some concerns around the IMR extension. I think a lot can happen between 6 and 12 months.

Those cases could presumably be redirected back to the health plan and resolved more quickly within the health plan prior authorization process. So for those reasons, we are opposed today, but do look forward to having continued conversations if the bill moves forward today. Thank you.

Thank you. Any additional witnesses in opposition?

Madam Chair and members, John Wenger, on behalf of America's Health Insurance Plans would just echo the comments [Unintelligible]

Darby Kernan, on behalf of the Local Health Plans of California, regrettably in opposition.

Thank you. I'll bring it back to the committee for any questions. Doctor Weber.

Good afternoon. I have a couple of questions or question and a statement for the opposition where exactly. Is it stating that they would be allowed to self refer and bypass the physician? Because that is concerning.

Thank you, Doctor Weber. The provision that we interpret, where we interpret that question is on, let's see and get the exact subsection review Section 11367.01. Subsection H says in determining whether to approve, modify or deny requests by enrollees or providers, we interpret that to mean that the enrollee themselves can then self refer for those utilization services.

To the author. Is that your intent? Because I would be very concerned if people are bypassing providers and doing a self referral.

I'd like my expert here to comment on that part.

Sure. Yes. Today already, it is not uncommon for enrollees to ask their health plans for pre certification of medical services. It's absolutely not the intent that AB 3260 alters the fundamental structure of health plans whereby, following such requests, they coordinate utilization review with enrollees providers. I have more information I'm certainly happy to share with all of the Members, but it's not an intention to create some sort of a fundamental difference.

And already certain health plan contracts that are regulated by DMHC actually put the onus on enrollees to seek pre certification. We have samples of such contracts we could share.

Can you clarify that with the opposition if this bill is to move forward? The other concern I have is I question the extension to 12 months. I understand if you think six months isn't enough time, but generally when you're dealing with getting a medical bill, you get that within a month or two of your service. And to say that it's going to take you 10 months to figure out that you need to dispute it, I think that's a bit longer.

So I would also ask the author to continue to work, to work with opposition or work with, you know, whoever is working with you on this bill to look at that a little bit more. Thank you.

We're happy to continue those conversations.

Thank you. Ms. Schiavo.

I want to thank the author for bringing forward this bill and think that, you know, I think it's really critical that these are decisions that are made with providers who are, you know, focusing on the care of the patients. And I do, I actually, I think it's fair to extend it that long because when you have someone in a mental health crisis, it's all consuming and it's all consuming for a while, it can take a while.

And so being able to have some grace and have some time I think is fair. And certainly it doesn't guarantee that you're going to be awarded that right but you have at least an opportunity to bring it forward. So just thankful for your leadership on this issue. Wanted to share that. I think that's reasonable. Thank you.

Well, thank you, Assemblymember Pellerin, for bringing forward this bill. This bill, I think, further strengthens California's strongest consumer protection, which is the right of an enrollee to complain and appeal a health plans denial pursuant to California law. I appreciate you for bringing forward this bill. With that, you may close.

Once again, I respectfully ask for your aye vote. Thank you.

Thank you. And when we have established quorum, we can consider that. I want to also thank you for asking far in advance for dispensation to go earlier. And I am going to committee actually present my bill, which is in file order right now. File item four, AB 1975. I have committee members who have been here or witnesses that have been here since 08:00 a.m. So with that. But first I will establish quorum. Secretary, please call the roll.

[Roll Call]

We have a quorum and we'll move to item four, AB-1975. Assemblymember Bonta proceed when you're ready.

Thank you. Good afternoon Chair and Committee Members. Food is life. Food is sustenance. Food is medicine. Food as medicine is a priority for me and is a legislative reparations priority for the California Legislative Black Caucus. AB-1975 would make medically supportive food and nutrition interventions a covered benefit to all Medi-Cal recipients when deemed medically necessary by their healthcare provider.

In addition, this Bill would mandate the Department of Healthcare Services to form a Committee on or before July 1, 2025, and issue final guidance by July 1, 2026, for the implementation of these intervention services. Our witnesses today are giving testimony and include Dr. Steven Chen, Chief Medical Officer of the Alameda County Recipe4Health, and Elizabeth Duran, Patient Participant in Recipe4Health. In addition, we have Katie Ettman, the Food and Agriculture Policy Manager with SPUR, to answer any questions. Thank you.

Thank you, Chair Bonta and Health Committee Members. My name is Steven Chen, and I'm a family physician with 24 years of experience in the safety net health system. I'm the Chief Medical Officer for Alameda County's Food is Medicine program called Recipe4Health. Why food is medicine? First, the bad news. The American people are sick with chronic health conditions and food insecurity. The good news is that food is medicine programs like Recipe4Health can help address this problem in your districts and across the state.

Recipe4Health equips safety net health providers to prescribe produce paired with health coaching to patients with food insecurity and or chronic health conditions. The produce prescribed is grown locally by BIPOC Farmers who are using regenerative and organic farming practices, which minimize toxic pesticide residue and increase the vitamin and antioxidant content of the produce grown. The following health outcomes have been reported by our evaluation team from UCSF and Stanford.

One third of our patients with prediabetes and diabetes and show a clinically meaningful reduction in their blood sugars. Two thirds of the patients improve their cholesterol indicators, thus reducing heart disease risk. Number three, food security improves by 25% and number four, emergency room visits are reduced by 15%. From a local or from an economic perspective, for every $1 spent on sourcing food locally from BIPOC Farmers, $1.90 is generated locally for the economy.

Recipe4Health is scaled to 10 health centers across Alameda County and served over 6000 patients. 83% of them identify as BIPOC. In closing, food as medicine programs like Recipe4Health can be scaled across the state by making medically supportive food, a permanent Medi-Cal benefit. I and the rest of the Recipe4Health team urge an aye vote on AB-1975. Thank you.

Hello, my name is Elizabeth Duran. I live in the East Bay and I'm here to share about my experience with Open Source Wellness and Recipe4Health. The pandemic caused me to lose my job of 30 years, including losing my health insurance. A knee injury led to surgery. I gained weight. I took medication for high blood pressure. My Doctor of 10 years prescribed anxiety pills for me. Soon after, I found myself on Medi-Cal and at Tiburcio Vasquez Health Center. I was terrified.

My new Doctor suggested a program which would include free organic vegetables once a week, plus health and wellness coaching called Recipe4Health. He described that I would learn about nutrition and be supported by a friendly community. Within a few days, I got a phone call from the Recipe4Health team to enroll me in the program. What I initially envisioned as a weight loss program turned out to be so much more.

Not only did I receive beautiful organic greens and vegetables, I learned of their nutritional value and how to incorporate them into my healthy diet in the most affordable way. I am cooking and eating much better today. I look for new recipes online that include collard greens and swiss chard, things that used to be unfamiliar. I learned how to incorporate different types of physical activity in my life.

In all my years with private insurance, no one ever asked me if I wanted to learn about healthy eating or offered resources. Open Source Wellness has made me feel wanted and cared for again. When I was turned away elsewhere, my worry has become less, my sleep more, my blood pressure is at a healthy level. I am feeling happy again and not from a pill.

I became so inspired that I stand as a peer leader of Open Source Wellness, wanting to inspire others who may be in a dim place as I once was. Californians across the state like me need these critical programs to support our health. I urge your aye vote.

Thank you. Other witnesses in support come forward. Name, organization, and position only.

Thank you. Darby Kernan I'm here on behalf of three organizations today. LeadingAge California, the Local Health Plans of California, and Project Open Hand. In support. Thank you.

Hello, Kristian Foy here, on behalf of Fresenius Medical Care and California Kidney Care Alliance. In strong support. Thank you.

Madam Chair and Members. Rand Martin here, on behalf of the AIDS Healthcare Foundation. This is a great Bill. Please support. Thank you.

Cher Gonzalez, on behalf of the American Diabetes Association. In strong support.

Kelly Brooks, on behalf of the County Health Executives Association of California, the Urban Counties of California, and the Rural County Representatives of California. Here in separate.

Christine Smith. Health Access. In support.

Sarah Nocito, on behalf of the California Chronic Care Coalition. In support.

Nicette Short, on behalf of Loma Linda University Health. In support.

Jennifer Snyder with Capital Advocacy. On behalf of Mom's Meals. In strong support.

Hi there. Mia Schwartz, with the Food as Medicine Collaborative. We're also a proud co-sponsor of the Bill, In support. And also from California Food and Farming Network.

Good afternoon. Louis Brown, on behalf of the American Pistachio Growers. In support.

Good afternoon. Symphoni Barbee, with Planned Parenthood Affiliates of California. In support.

Ryan Spencer, on behalf of the American College of OBGYNs, District Nine, and the Crohn's & Colitis Foundation. In support.

Thank you very much. Dylan Elliott, on behalf of the City and County of San Francisco as well as the California Medical Association. Both in support. Thank you.

Hi. Carli Stelzer, on behalf of Family Meal Sacramento. In support.

Whitney Francis, with the Western Center on Law and Poverty. In support.

Jedd Hampton, with the California Association of Health Plans. Apologies for not getting our letter in on time, but we are in support. Thank you.

Lucinda Bazile, with LifeLong Medical Care. In support.

Thank you. Do we have any witnesses in opposition? Seeing none. I'll bring it back to Committee. We have a motion. Do we have a second? Yes, Miss. Weber.

I just want to really thank the Chair once again for bringing this Bill back. It is extremely important. You know, I think someone in the audience said it best. It is a great Bill. It's more than a great Bill. And hopefully this time we'll be able to get it all the way through into the governor's desk and signed. I'm really happy to see the very wide, diverse support here.

The coalition of support recognizing, as was pointed out by your two witnesses, that we can really lower the cost of healthcare, get people off of medications, prevent hospitalizations, prevent unnecessary surgeries. If we take this kind of proactive approach and ensure that things that they are eating are healthy and safe, then we wouldn't see all of the obesity, the diabetes, the high blood pressure, all of these chronic illnesses that we're seeing not only in our older population, but also in our pediatric and adolescent population.

So I really want to give our Chair your kudos. This has been something you've been talking about since you came into the Legislature. I'm very proud that you allowed this to be one of the Black Caucus Priority Bills. And just really thank you for bringing this back up again.

Yes.

I would just like to echo Assemblymember Weber's comments. I love this Bill. Thank you very much for bringing it forward. And I'd like to be added a co-author.

Miss Schiavo.

I'd also love to be added as a co-author. I think this is such an impactful Bill and there's, you know, so much we can do to really address health if we approach it in this way. Thank you.

Any other comments? I agree with the comments. I think amazing it took this long for us, our society as a whole, to understand how important nutritious foods are, especially in preventative medicine. So we do have a motion and the second do pass to appropriations. Would you like to close?

Thank you. I certainly am thankful for the co-author request and willingly accept those. I just want to thank Miss. Duran, actually, who I've got gotten to spend some time with over the past couple of hours, and thank you for being here.

But she talks about swiss chard and our need to be able to make sure that we are using that and incorporating that into a healthy life. And I want to just kind of highlight her story because we could have so many Californians who are able to tell the same story instead of telling stories about how they went to the emergency room or needed gastric bypass surgery or needed to start taking pills for A1C or all the other things that we can do.

This is a very simple fix. And if we're smart, we know that it will cost very little compared to how much it costs us right now to be able to support people. So with that, I respectfully request your aye vote.

Thank you. Madam Secretary. Please call a roll.

[Roll Call]

[Roll call]

9 votes. Your Bill is out. I see Miss Reyes out there. Next on the list, AB 2066.

Assembly Member Reyes, please begin.

Thank you, Madam Chair and Members. Today I am presenting AB 2066, the Clean Coffee Act. I would like to thank the Chair and her staff for working with my team on this Bill and commit to taking the amendments, narrowing this Bill to a labeling requirement consistent with the RN shared with the Committee. As proposed to be amended, AB 2066 will require the labeling of decaffeinated coffee products that utilize a method utilizing methylene chloride. I introduced this Bill for a number of reasons.

I found out that there were three ways to decaffeinate coffee, three processes, and one of those uses methylene chloride, a known carcinogen, and so we've worked to try to take care of that issue. I can tell you that the impact on pregnant mothers who switched to decaffeinated was the biggest concern that I had.

When I was pregnant with my son, it was recommended that I switch to decaffeinated coffee because of the potential negative impacts of consistently consuming regular coffee and the impact that would have on his health. I must admit I was shocked when I found out that methylene chloride is commonly used as a method for decaffeinating coffee beans and that it has a potential to leave elements of this toxic substance in coffee once the process is completed.

Methylene chloride is a substance that has been used in paint strippers, as a chemical and bathtub refinishing, and as well as several other industrial uses. It has now been banned. It can be contracted by breathing it in or through direct contact, and it has been scientifically proven that during pregnancy, methylene chloride contamination can be passed from mother to child. Given these impacts, regulations regarding the use of methylene chloride due to its risks have escalated over the past few years.

In April of last year, the U.S. Environmental Protection Agency banned most uses of methylene chloride, citing it as a dangerous, and I quote, dangerous chemical known to cause serious health risks and even death. End quote. Currently, the Environmental Defense Fund is petitioning the FDA to ban methylene chloride's use in foods altogether. As mentioned earlier, it's important to note that this is not the only way to decaffeinate coffee. There are three types of methods used to decaffeinate coffee. First, the supercritical carbon dioxide method.

Number two, the Swiss water press method, also known as a water process used by companies like Pete's Coffee. And third, the methylene chloride method that is the subject of this bill's notification requirements. I've heard various opposition points highlighting concerns with the Bill. However, given variances in the level of methylene chloride left during this process, combined with the fact that almost all of the caffeination occurs outside of the country, I continue to be concerned regarding the use of this method when there are clear alternatives.

AB 2066 will provide consumers with an opportunity to make an educated decision regarding their choice in the use of decaffeinated coffee. Here to testify in support of the Bill are Jackie Bowen, founder of the Clean Label Project, and Susan Little, Senior Advocate for the environmental working group.

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

Thank you. Chair and Members, I'm Jacqueline Bowen, representing the Clean Label Project, a national nonprofit with the mission to bring truth and transparency to consumer product labeling. Before coming to Clean Label Project, for 15 years, I worked for NSF International, the World Health, the World Health Organization Collaborating Center on Food Safety and Water Quality. However, my most cherished role is that of a mom of a two-year-old son.

It's because of my personal and professional interests and passion that Clean Label Project focuses its advocacy efforts on supporting infant and maternal health. We've been actively involved in supporting recent legislation, including California's AB 899, which mandates heavy metal testing and disclosure for baby foods. In similar bills such as Rudy's Law in Maryland, these initiatives aim to protect the most vulnerable populations in our society, and that's why I'm here today.

The Bill we're discussing pertains to the use of methylene chloride, unknown carcinogen, in the decaffeination process of coffee. The Environmental Protection Agency banned methylene chloride for most consumer, industrial, and commercial uses to safeguard the public health, with the notable examples including the prohibition of the use of methylene chloride for paint stripper. However, despite these regulations, methylene chloride is still permitted for use in food products, which falls under the jurisdiction of the FDA.

The Bill addresses a critical this Bill addresses a critical regulatory gap in California by questioning whether a chemical like methylene chloride, linked to cancer and banned in many industrial applications, should be allowed in coffee decaffeination, especially considering there are readily available non-carcinogenic methods of decaffeination utilized by numerous coffee providers at comparable costs, and especially considering that the consumers reaching for decaffeinated coffee are oftentimes pregnant women, the elderly, or others with medical conditions. Canada requires labeling.

The simple question posed by this Bill is, should we require mandatory labeling of decaffeinated coffee products that use this known carcinogen, methylene chloride, for decaffeination purposes. Yes. Thank you, and I'm available for questions.

Thank you, Committee and Chair. Good afternoon. My name is Susan Little and I represent the Environmental Working Group. EWG rises in support of AB 2066 because we and many other public health organizations are not at all confident that the U.S. Food and Drug Administration will take meaningful action to prevent consumers from consuming this carcinogen. Since 1958, the law was unambiguously stated that carcinogens are not safe to use in food.

By 1986, government studies established that methylene chloride causes cancer, yet the FDA has taken no action to remove it from the food supply or to warn consumers about its presence in food. In fact, the FDA routinely fails to adequately oversee chemicals in the food supply and is not required to re-review additives that it's approved or allowed or act on new scientific evidence of harm caused by those additives.

As a result, many food chemicals such as methylene chloride have not been meaningfully evaluated by the FDA for many decades, well past the time when those studies are. Those studies don't, no longer are relevant in terms of they don't measure up to the same toxicology standards as they use today. Years after the FDA approved the use of methylene chloride in food, it looked at the chemicals use in cosmetics.

Based on that review, the FDA determined that methylene chloride is a carcinogen and prohibited its use in cosmetics in 1989. But FDA continues to allow it to be used in food, even though the law specifically bars FDA from permitting carcinogens to be food additives. California scientists at CalEPA have also concluded that methylene chloride can cause cancer. And most recently, the EPA has determined that methylene chloride is not safe for any consumer use.

Makes no sense that a known carcinogen is allowed in our food, especially when its use is not necessary, not to mention in violation of federal law, and consumers should be warned. Thank you.

Thank you. Are there any other additional witnesses in support?

Ryan Spencer with the American College of OBGYNs recently approved a support position on his Bill. Thank you.

Hello. Karen Stott, on behalf of Reproductive Freedom for All California in support.

Are there any primary witnesses in opposition? Please come forward and sit at the presenter panel, please. You'll each have two minutes.

Good afternoon, Madam Chair, Members of the Committee. I'm Bill Murray. I'm the CEO and the President of the National Coffee Association. We strongly oppose AB 2066. The bill's sponsors have presented no evidence to justify placing warnings on decaffeinated coffee, the majority of which is European method decaf coffee, which utilizes methylene chloride. They've not presented any evidence because no evidence exists.

Governments around the world, including the European Union, authorize European method decaf as safe. Decades decades of independent scientific research show that decaffeinated coffee, like all coffee, is actually associated with the reduced risk of multiple cancers and other diseases. There's no evidence showing an association between European method decaf coffee and increased risk of cancer. Quite the opposite.

The World Health Organization, the American Cancer Society, the American Institute for Cancer Research, the World Cancer Research Fund, and California's own Office of Environmental Health Hazard Assessment have all determined that drinking coffee, both regular and decaffeinated coffee, decrease the risk of endometrial cancer, liver cancer, and several other cancers and chronic diseases. The only remotely relevant evidence finds increased risks observed in rodents when they've been exposed to the equivalent of 30,000 cups of coffee a day.

European method decaf has absolutely no relation to other products that contain methylene chloride. Any such comparisons are misleading. Furthermore, there's zero evidence the European method presents any risk for pregnant women. According to the CDC's public health statement, and I quote, there have not been any reports of a connection between methylene chlorine exposure during pregnancy and birth defects in humans. I understand that just a couple of hours ago, the Committee has proposed amendments to require warnings.

I'll turn to Anthony Samson to discuss our concerns with that proposal in more detail.

Great. Thank you. Chair Members. Anthony Sampson, here on behalf of the National Coffee Association, did not intend to come up here today, but given the late amendments, just wanted to make sure to speak a little bit about those. Before doing that, I just want to reemphasize two points that Bill Murray made that are critical to keep in mind when reviewing the amendments before you. First, there is no evidence, there is no data, no science linking European method decaf to negative health outcomes.

Second, there is a plethora of evidence, data, and science which we have provided to Members of this Committee and to the Chair showing just the opposite, that drinking coffee, including decaf, the majority of which is European method decaf, has significant health benefits. These points seem to have resonated with many Members of the Committee and as such, we have now shifted to a ban on from a ban on European method decaf to proposing a warning for it.

But while the approach has shifted, the body of evidence remains exactly the same. There was no evidence to support a ban and there is no evidence to support a warning. To be clear, the warning proposal before you is by its very nature suggests that a health-protective product is unsafe. There is no sense at all in warning consumers about a product that is proven safe and associated with decreased risk of multiple types of cancer.

The warning, by its nature, of calling out one chemical would mislead consumers into being frightened of this product, despite the overwhelming body of evidence suggesting that they should not. For those reasons, we request a no vote and happy to answer any questions.

Any additional witnesses in opposition?

Katie Little with the California League of Food Producers, in opposition.

Thank you, Members. Rob Spiegel, California Manufacturers and Technology Association, in opposition.

Jennifer Snyder with Capital Advocacy, on behalf of the California Retailers Association, in opposition.

Dennis Albiani, on behalf of Consumer Brands Association in opposition.

Good afternoon. Louis Brown, on behalf of the California Grocers Association, in opposition.

I'll bring it back to the Committee for any questions or comments. Doctor Weber.

God afternoon. Thank you for bringing this Bill forward and allowing for us to have this very robust conversation. Now, in the presentation, someone mentioned the fact that there are already labels in another country. Can you elaborate on that? Is this warning label already precedent anywhere else? Or would United States be the first?

There is some labeling that is currently occurring in Canada. There is also prohibitions that are happening in Japan and Korea, if I understand correctly.

Can you explain that labeling? Where is the label? What exactly does it state?

I can get back to you with more information on that.

Okay. Well then, since there were last minute amendments and we haven't seen it, what is the thought process behind the labeling? Where is it going to go? What is it going to say? Do we have that?

The label, the proposed label just discloses that the product was made with methylene chloride process.

Okay. And where is it going to go? Is it on the packaging where the person who owns the store is going to see it? Is it on the cup where the consumer can see it? Where, where are we thinking that the labeling is going?

The label would go on the package itself in a clearly, clearly a clear place.

Okay. So the consumer wouldn't necessarily see it.

They would see it on the external part of the package. Yes.

But if you go to a. If I go to Starbucks, right? I don't see the.

No, you don't.

Right. So they wouldn't see it. It's just the store. Okay. And there's been a lot of discussion about what the evidence actually shows. So we know that in large quantities this is a health risk. Has there been any specific studies that has looked at this particular method in coffee and linked that to any adverse health outcomes?

The one thing I would say to that point is just as there has been an evolution of the decaffeination process methods over the past 40 years as it relates to medical ethics and clinical trials, I think it would be difficult to conduct something to assess, provide that type of exposure to intentionally see at what point is there an adverse health effect on an unborn child? In terms of finding any deliberate human studies, I know that there's some in animals right now.

Well, I completely understand that. We're not. It would be very unethical to do that. However, we can do retrospective studies. So if you see that there is a commonality, we can always go back and assess if there is a common factor, i.e. decaf coffee, like in pregnancy or something. So my question is, do we have that evidence? Because oftentimes when we realize that something may be an impact or cause an impact to someone's health, it's not that we haven't intentionally done it.

We notice a trend and we look backwards to find that common denominator. Do we have that for this particular?

Doctor Weber, thank you. I want to point out that the studies that the gentleman next to me have talked about, that those studies don't specifically call out the coffee that has been, that has been treated with methylene chloride. They're talking about, of course, studies in general about coffee and whether it has it or doesn't, that's not necessarily part of what they're discussing.

Also, the 30,000 cups that they're discussing, you know, the figure they mentioned, that would result in a risk factor of one in 10, one in 10 persons getting cancer. And that is a risk factor. That is not an acceptable risk factor put forward by any public health organization. Usually, it's a one in 100,000 or even a one in a million risk factor that is considered a safe level or an acceptable risk factor.

Also, I just wanted to point out that when CalEPA looked at methylene chloride to determine the public health goal for drinking water, they determined that the public health goal for drinking water would be no more than four parts per billion, which is 2,000 times below the FDA's acceptable standard. So I just wanted to just give you an idea that there are ingestion studies.

The public health goals, both at the CalEPA level and also at the EPA level, look at methylene chloride from the standpoint of what could happen to a person when it's ingested. And the EPA determined that the public health. That the goal, the maximum contaminant level goal for drinking water from ethylene chloride was zero. Similar to lead. Right? So it's one of those carcinogens that even the FDA decided to just say that they couldn't even be in cosmetics.

One of the few chemicals that can't be in cosmetics is methylene chloride.

I would like to hear from the opposition on this.

Doctor Weber, to address your concern of research. All the research that we have mentioned was conducted independently of the industry. We do not support research. It's all available on the Pub Med system. Let me address just one study because there are literally hundreds of them. And you were speaking about prospective and retrospective studies. This is a meta-analysis that was done by Kennedy in 2017. He looked at 18 cohort studies respectively, and eight case-control studies, specifically at decaffeinated coffee.

The majority of which is produced with methylene chloride, European method. He was looking in particular at liver cancer. The reason is because the supporters alleged that methylene chloride is associated with liver cancer. So looking at the disease endpoint and the research gives us some indication of what the facts are and what science tells us. The authors looked at 2,272,642 people. They concluded, and I quote, increased consumption of caffeinated coffee and to a lesser extent decaffeinated coffee are associated with a reduced risk of liver cancer.

And again, very specifically, this is hepatocellular carcinoma. So specifically a reduced risk of HCC, including in people who had preexisting liver disease. The authors went on to say these findings are important given the increasing incidence of liver disease globally and its poor prognosis. This is simply one example. It's all available publicly, non-industry supported, and it all is consistent, as this meta-analysis or literature review select suggests. This is not selecting one study or another, as you would appreciate. Thank you.

Thank you.

Madam Chair. I think that what is important in our presentation of this Bill, here are the scientists. But for me, it's the fact that methylene chloride has been banned even in paint strippers. It is a process used for decaffeination and it is one of three that can potentially be used to decaffeinate coffee and it is not done in California. The decaffeination of using methylene chloride is not even done here in California. It is done outside of California and it is then imported here.

I think that as we move forward in the discussions, the objections from the opposition are well taken. But I think that a person who is going to ingest a cup of coffee has the right to know which method is used and if methylene chloride was used, even if it is trace elements that are left in that cup of coffee, I would want to know that that was the method that was used and that it is not completely evaporated.

It remains in there and it depends on which coffee. There were blind studies that were done that show more methylene chloride in some of these cups of coffee compared to others. But the fact that it still remains in that cup of coffee, knowing that there are two other methods of decaffeinating coffee, I think is what is important here. One of the one argument was, it's going to cost so much more. Well, there are a number of coffee. I'm trying to find my notes.

The companies that use the alternative methods include Pete's Coffee, Dutch Brothers, McDonald's, Folger's, Temple. There are others, but those we know for sure use anything but methylene chloride and their coffee prices. I'm sure we're all coffee drinkers. Most of us are. We have some tea drinkers, but most of us are coffee drinkers. And if the price is going to go up a few cents, we get to make a choice. And that's really what this is about.

If you know methylene chloride is being used to decaffeinate your cup of coffee, you should know. And if you feel that it's just a trace element, you get to decide that if that's the cup of coffee you want to drink.

Doctor Weber, you have an additional question.

Just one more comment. We'll see what happens with the Bill. But if that is the goal, to inform the consumer or let the consumer know, just recognize that the consumer does not see the actual package. So if that's where the label is going to go, the consumer is not going to see that.

And I absolutely, I'm so glad you brought that up. And this Bill is double referred. It will go to Judiciary next. And I think that that is something we're going to have to remedy, because you are absolutely correct, it is the consumer who should know what is in that coffee.

Well, I don't drink coffee, but I've certainly spent a lot of time looking at this Bill. And I want to appreciate my Committee staff for really being able to sift through the 400-page EPA report. Many different scientists, hearing from both proponents and opposition on this Bill. And I just want to make sure that we are kind of setting a precedent where we are actually basing our policy recommendations on science.

And so I know, author, you are incredibly passionate about this issue, and I appreciate you having many conversations with me about this. I still have major concerns with the depiction of what has so far not been research-based. There is no evidence to support that there is passage of methylene chloride through the drinking of decaffeinated coffee from pregnant individual to the fetus. We just don't have the science to support that.

We do know that a report published in the International Journal of Food and Nutritional Science that the average American coffee drinker is expected to consume 50-fold less methylene chloride than the EPA suggests could be immediately harmful. And 100,000 fold less than the amount that has been linked to cancer in rat studies. We have a lot of evidence to the contrary of what has been presented here today.

However, I know that you are incredibly passionate about this Bill, and at some point, we will need to make sure that we are weighing the concerns, legitimate concerns, to want to have healthy babies and have people be healthy overall and whether or not through this particular form of decaffeination use of this process, it results in any cancer. I just also want to clarify that many of the studies that have been shared are focused on inhalation and dermal contact in large quantities.

It makes sense that methylene chloride is prohibited in paint thinners where people are inhaling over massive amounts of time repeatedly. The substance that is not the case when it is in very small trace amounts through this dechlorination process associated with decaffeinated coffee.

With that, I want to just share that, I will be supporting this Bill today with the amendment striking the ban of the use of methylene chloride in the process of decaffeinating coffee and the sale of coffee that has been decaffeinated using methylene chloride and replacing these provisions with the label of the final coffee product that states methylene chloride is used in the decaffeination of the product.

I will note my overall, quite frankly, discomfort even with that and know that this will go on to Judiciary Committee where you will continue to work on this Bill and with our staff to refine that language and to address some of the concerns that were raised by the Committee thus far and seeing no other comments from the Committee. Go ahead.

I want to thank you. You know, I have a lot of concern on this Bill. Labeling is not always going to be the answer.

I've done bills on labeling, and they are very difficult. They're costly. So I'm willing to give you a chance to get this right. I don't know that I'm going to be convinced to vote on it on the Floor. I think we're really splitting hairs here. And you know, when you say you're going to buy coffee from whatever vendor, no one knows. No one's going to look at a label on a coffee cup. They're just not.

So with that, I will support your Bill today, but I will be taking a second look at it before it hits the Floor.

Assembly Member Waldron.

I just want to say also, I know a lot of work has been done on this Bill. I have the amendments here in front of me, and they'll be put into the Bill between now and Judiciary. I'll get to see it again in Judiciary. So I'll be giving it a courtesy vote today to see what happens with it. Thank you.

Miss Carrillo.

Thank you, Madam Chair. And thank you to the author and the witness testimonies, as well as the opposition that's here today. I think when I first heard about the Bill, I had some questions related to, well, one, who is processing the coffee, right? What is it going to look like if it's being imported since clearly that process is not done here in the state, questions about labeling, questions about vendors, questions about coffee shops. How exactly will the public know?

I think in Health Committee, and I've had the privilege of serving this Committee for the past, since I was elected, actually, we hear a lot of bills related to what is now. I think a common theme in terms of, like, is our food safe? How are we processing food? And what are the connections between the chemical processing of a variety of different things that we consume and drink and the impact that that has on our health?

And so it's raising a consciousness, I think, of just the production of the food quality in America compared to other places. And my parents drink coffee. I'm a coffee drinker. I'm drinking tea now because I've had maybe four cups of coffee all day. But we drink decaf at night. My parents are decaf drinkers in the evening as well. I'm on the website now, like the check your decaf.org, and wondering, you know, is the brand that they drink safe or not?

Some of the questions that I had with you, and I'm glad that we had an opportunity to talk over the weekend, was just the scientific study behind what it is that you're proposing, as well as the opponents. Thank you for taking time and sending me information as well. I think the concern that I have is one, just the science around it, right? What's safe, what's not? But I have questions about a variety of different types of food-related to that.

And ultimately, at the end, like, how do we, how does California, just one, create a policy that's going to impact nationwide in terms of, like, the import-export, creation, business, healthcare, etcetera? And how do we make that a reality? And how do we just consume in ways that are healthy for us? I'm looking at, I'm looking at the website now, and I'm also reading now that, I'm not sure I'm pronouncing this right. Ethyl acetate is also potentially another chemical that's used.

Yes, it is.

And is that safe or not? And should that be included in the Bill or not? I have no idea. I'm just kind of reading and not knowing enough about the science just makes me wonder what the best process of coffee is, which is my concern, and really what the best way is to move forward. I'll be giving it a courtesy aye to today to allow you the opportunity to move forward and have the policy discussions.

I do Reserve my ability to be able to vote differently or not at all on the Assembly floor. I do want to see, I do appreciate you doing the work necessary to at least try to inform the public and also taking a look at what the FDA is doing nationally on this as well and what that could potentially look like for those of us that do proudly consume coffee.

And just want to do it in a way that's safe as well and using all the scientific methods to really, truly understand that. So again, I appreciate the conversation and all the work that the Committee has done as well to move this, to really give us the opportunity to review the policy. So thank you, Madam Chair.

Thank you again. I will be giving this a courtesy aye at this point now. Know hat we need to continue to work on this Bill in Judic. and beyond. I want to recognize and appreciate the passion that the author has brought to this issue and the concern that she's raising for our overall health. I also want to recognize and acknowledge that although I don't drink it, coffee is very healthy for us. And there are many studies that show decaffeinated coffee included, show the pure benefits of it.

So it's a lot for us to be able to kind of weigh the overall kind of public health implications of this Bill. That is our job as Legislature. Right now, we've settled on amendments to provide a label. I believe that the language of the label still needs a lot of work. It will move on to Judiciary, where that will happen in concert with our staff here in Health. And with that secretary, please call the roll.

Oh, I need a motion. Moved by your Arambula. And a second? Seconded by Schiavo. The motion is do pass to Judiciary, as amended to Judiciary. Please call the roll.

[Roll call]

That measure is out nine to one.

Thank you.

Thank you. We're going to take a moment now that we've established quorum to do the consent calendar I've previously read. So we have a second by a motion by Aguiar-Curry. Seconded by Doctor Arambula. Please call the roll.

[Roll call on consent calendar].

Consent calendar is out with a vote of 10 to 0. We will move on now to item number 8, AB 2098 Garcia.

Good afternoon, Madam Chair and colleagues. AB 2098 provides district and municipal hospitals a much needed lifeline when it comes to extending the repayment for the terms of the California Finance Authority. Bridge loans. As we all have been made aware, there are a number of different hospitals up and down the State of California that are at the verge of financially breaking. Well, at the verge of closing its doors. And these hospitals find themselves in medically underserved parts of the state.

That's why this Bill is before you, is to help those hospitals stabilize themselves. We have a witness here who will be very brief and respectfully ask for an aye vote.

Moved by Aguiar-Curry. Seconded by Sanchez. Please go ahead with two minutes of testimony.

Good afternoon, Madam Chair and Members. Connie Delgado, on behalf of the district hospital Leadership forum and we want to thank the author for his commitment and many of the Members here for their commitment for these hospitals who have struggled over the last few years. In budget year 21 and 22, district hospitals received $40 million in bridge loans.

And this Bill will look to impact year two of those bridge loans, asking for just a little more time to repay those loans and allow a lifeline for these hospitals to keep their doors open and continue to provide services. We respectfully ask for your. I vote. Any other witnesses and support? Thank you, Madam Chair Member Sarah Bridge, on behalf of the Association of California Healthcare Districts and strong support. Thank you.

Vanessa Gonzalez, with the California Hospital Association here in support.

Thank you. Any witnesses in opposition? Seeing none. I'll bring it back to the Committee for comment. Seeing no comment from the Committee, we have a motion in a second. Secretary, please call the roll. Sorry, would you like to close? It's do pass to appropriations.

[Roll call].

That measure's out 10-0. Thank you so much. We'll move on now to item number nine. AB 2105. Lowenthal.

Assemblymember Lowenthal, please proceed.

Thank you so much, Madam Chair. We have another witness who is in the restroom who will be joining. Boy, all this talk on coffee, down to one cup a day.

Thank you, Madam Chair and members. Very pleased to present AB 2105, which requires a healthcare service plan, contract, or health insurance policy issued, amended, or renewed on or after January 1, 2025, to provide coverage for the treatment of pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections or PANDAS, and pediatric acute-onset neuropsychiatric syndrome, or PANS prescribed or ordered by a physician or surgeon. I'd like to start by accepting the committee amendments and thank the Chair and committee staff for their very thoughtful work on this bill.

PANDAS and PANS are an inflammatory disease of the brain. They result in sudden onset, devastating behavioral and neurological dysfunction that usually occur after a triggering infection. These disorders are thought to be caused by autoantibodies generated after the infection that mistakenly attribute attack the brain. Antibiotics or oral anti-inflammatory medication help most children, but a minority need stronger immune-modulating treatments such as intravenous immunoglobulin or IVIG.

Despite published PANDAS and PANS treatment guidelines that established a standard of care in 2017, insurers have continued to adhere to their own policy statements forbidding authorization of immune-focused treatments such as IVIG. As a result, treatments are routinely denied. Early and expedient treatment of pandas and pans is essential in order to prevent long-term and potentially life-threatening impacts of these conditions.

Patients seeking immune-modulating treatments for acute PANDAS and PANS are frequently denied authorization for these treatments by insurers and must seek independent medical review at the Department of Managed Healthcare. While the IMR process is effective, decisions are typically rendered within 30 days of qualification, meaning that the insured must first receive a denial from their insurer, file a request for independent medical review, and wait for a decision to uphold or overturn the insurer's denial, but unfortunately, it's too late.

This timeline is simply too long for children suffering from PANDAS and PANS and is frequently leading to kids receiving treatment long after current treatment guidelines recommend. According to the clinical management of pediatric-onset neuropsychiatric syndrome, early care for PANDAS and PANS patients is defined as receiving treatment within two weeks of diagnosis; late care is defined as receiving treatment within two to four weeks of diagnosis, and very delayed care is defined as receiving treatment more than four weeks after diagnosis, based on published clinical treatment guidelines.

For PANDAS and PANS, denials are frequently resulting in very delayed care for pandas and pans patients, which results in worse health outcomes for patients and the need for long-term care, which results in greater costs to patients and their families, insurers, and the state. They say timing is everything, and in the case of pandas and pans, couldn't be more true. Early and expedient access to the treatments is crucial to the effective treatment of PANDAS and PANS.

In order to avoid the debilitating symptoms, potentially permanent neurological damage, sometimes fatal outcomes associated with these disorders. AB 2105 will ensure that individuals and families who are confronted with these disorders do not experience unnecessary delays in treatment that can lead to disastrous and tragic outcomes. It is my pleasure to introduce Doctor Angela Tang, the mother of a PANS child, and Doctor Susan Manfull, Co-Founder and Executive Director of the Alex Manful Fund, who are here to testify in support of AB 2105.

Thank you. You'll each have two minutes.

Thank you. Good afternoon, Madam Chair and other members. Thank you very much for allowing me to address the committee on this very important topic today. My name is Susan Manfull. I am a native of Fresno, California, although now I live in New Hampshire. I have very strong ties in my home state here. But I have come to see you today specifically to testify about this bill. I am the co-founder and executive director of The Alex Manfull Fund.

As Assemblymember Lowenthal just said, as this group supports research and education, and awareness in PANDAS and PANS. But I am here today as a mother because my daughter, Alex, cannot be here today. She's no longer alive to tell her story. So I'm going to tell it for you in two minutes, I promise. She was a paragon of health. 1 minute remaining. Okay, I'm not talking fast enough. All right. Until she had strep. At the same time that she had mono. She was our only child and she lost her life at 26 years old in 2018 because she did not have timely diagnosis and treatment. In fact, she diagnosed herself with PANDAS. And then, she was able to get an appointment with a top neurologist, who confirmed her suspicions and ordered treatment. My husband and I, my daughter then worked to prepare for this notorious battle with insurance companies. However, she died before she was able to get treatment.

We donated her brain to NIMH and to Georgetown, where we established a brain bank called POND. That stands for PANDAS/PANS and Other Neuroimmune Disorders. It's the only brain bank in the country. So, may I have 30 more seconds? Okay.

Thank you. Hers was the first brain in that bank. And in less than three years, we have seven brains there. The youngest one is 14 years old. Most of them are teenagers. This is a remarkable growth for a disorder that's so little known and a brain bank that has not yet been promoted. Now, I'm talking about these brains as if they are commodities. They are not.

In fact, I want to let you know that today, the family who donated one of the brains is celebrating the 17th birthday of that young person who died due to PANDAS. In Alex's brain, I can tell you the damage in her brain if you'd like, but she sustained brain damage. There was evidence of inflammation exactly where the clinical symptoms suggested that damage should be and where the brain scans suggested that they should be. She had gliosis in her brain.

That's evidence of brain damage that's seen in Alzheimer's patients, in MS patients, and other very serious neurological disorders. So please vote. Please support this bill. Thank you very much.

Thank you. Please go ahead.

I'll talk fast. My name is Doctor Angela Tang. Five years ago, PANS struck down my 15-year-old. My healthy soccer player could no longer walk, and my straight-A student couldn't write. He spat out food if an intrusive thought struck, and he needed me at his side, even during his tortured sleep. We dropped out of school, work, and life. With two doctor parents, my son got every oral medicine in the 2017 treatment guidelines by expert clinics like Stanford and Harvard.

When he could no longer drink, he was scheduled for a feeding tube. The guidelines say that the next medicine is IVIG, but policies by Anthem, Aetna, and others say that IVIG is not medically necessary, experimental, and unproven. I luckily worked for a large medical group, issuing authorizations and denials for 15 years, and my doctor connections got him IVIG with improvement in a week. No feeding tube. Today, he's off medicines, and he's a pre-med in college nearby. And one day, he may be your doctor.

My son got IVIG seven weeks from onset. According to the guidelines, past four weeks is very delayed care. But of the hundreds of cases I've seen, including at the Stanford PANS Clinic, where I am now an adjunct clinical associate professor, not one has received IVIG faster than my son. The norm is months to years of brain inflammation before insurance agrees to pay or is forced to pay by regulators or parents sell off assets to pay or kids get institutionalized or they die.

My opinions are my own as an insurance insider, parent and pans researcher, and today I make good on the oath I took to become a doctor when I ask you to protect the youth who lack doctor parents. Some say that existing regulations where insurers use policies by nameless employees who have never heard of this diagnosis to automatically deny ivig and then have 30 days to respond to a appeals are sufficient for this urgent diagnosis.

Please consider if insurer definitions of medical necessity should violate peer reviewed clinical practice guidelines by which AB 2105 defines medical necessity. Let's stop insurers passing the buck to taxpayers and special ed unemployment and disability. This bill costs $7,000 to enact and less than a penny in insurance premiums. Just to wrap up today, I give voice to the youth whose brains lie at Georgetown and to doctors who are shackled in their attempts to help. And today, you choose for California's kids,

Know for Alex's path or I for my son's path. Thank you very much.

Thank you. Are there any other witnesses in support? Please line up.

Good afternoon, Madam Chair and members. Thank you to the author, Awet Kidane, representing the California Children's Hospital Association. Very, very strong support. Important bill. Appreciate you.

Thank you. We'll do name, organization and position only.

Erin Taylor on behalf of the Memorial Care. Thank you. Please support this Bill.

Mitch Steiger with CFT, a union of educators and classified professionals. Also in support.

Brandon Marchy with the California Medical Association. In support.

Nicole Moroles, on behalf of Children Now, in support.

Jennifer Snyder with Capitol Advocacy on behalf of the California Life Sciences. In support.

Chris Whitty, PANS patient since three years old. In support.

Doctor Denise Calaprice, a clinical researcher at Stanford PANS Clinic, speaking on my own behalf. I'm the author of several of the studies that Angela mentioned and the parent of two kids who did get very early treatment for PANS and very successful treatment. And I'm here in strong support.

Kelly Reilly, PANDAS mom, in strong support.

Diana Pohlman, Executive Director of PANDAS Network. I represent over 40,000 families nationwide and worldwide. I'm in strong support. Thank you.

I'm Don Pohlman, the father of Garrett Pohlman, who was the first child in California in 2007 to receive IVIG. As a footnote, just recently, he graduated top honors from Berkeley in chemical engineering.

Thank you, David Gonzalez on behalf of America's Physician Groups and strong support of this important measure.

Sherry Strollson, PANS mom and member of the California Coalition for PANS/PANDAS Advocacy, I support AB 2105 with all my heart.

Doctor Jamie Candelaria Green. I'm a researcher in special education and author of works on PANS in education, and the proud mother of a survivor of this dreadful disease who's now serving in our military. I strongly support this bill. Thank you.

Hi, my name is Jensen, and I have PANDAS. We need your support. Kids cannot keep suffering. Thank you.

Hi, Elise Tavsberger, parent of Jensen and also Emory. Em, Can you say hi? 11 years old, one adopted, one biological, two PANDAS/PANS. We need you guys. It's time. Thank you.

Jonathan Tavsberger. Like a defibrillator for cardiac arrest, IVIG saves lives. Our kids, we saw it save -

It's just name and organization, household affiliation.

Thank you for supporting 2105.

Thank you.

Saves lives.

My name is Violet Rodriguez Sofer, and I'm a proud mother of a 17-year-old with PANS and PANDAS. I support this strongly. Thank you.

Excuse me. Good afternoon. David Sofer, father of 17-year-old Miranda, who is suffering from this crushing disease, and IVIG is helping her. Thank you. In support, strong support.

My name is April Ronet. I'm with the California Coalition for PANS/PANDAS Advocacy. I'm a public school teacher, and I strongly support this bill for my son, Aiden, and all children who need access to this medication. Thank you.

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

Thank you. Madam Chair, members of the committee, Jed Hampton, with the California Association of Health Plans here, regrettably, in opposition to AB 2105, we would like to thank the author, his staff, committee staff, and I do want to, you know, acknowledge and thank the witnesses here in support. Obviously, it's a very tough, very sensitive issue, and we certainly realize that and understand that and are certainly sympathetic to that. So, I did want to acknowledge all the witnesses here in support today.

I do want to point out that our primary concern with the bill is related to the absence of the medical necessity language, which is a standard condition for health plans in determining the coverage of specific services. In reviewing the committee analysis, it does appear that the author is going to be addressing that issue via amendments. We have not seen the amendments or the language yet on that, but we are looking forward to reviewing that with our membership and seeing where that takes our member plans.

We would also point out that both the Assembly and the Senate Health Committee chairs have introduced bills this year to begin the process of reviewing California's essential health benefits benchmark plan for the 2027 plan year, and we do think that that is something that we do support conceptually and think that that's probably a better way of handling some of these benefit mandates moving forward. So look forward to being a part of that process. But we are opposed for the reasons.

Look forward to seeing the amendment shortly. And again, thank the author, the sponsors, and the witnesses here in support.

Go ahead.

Steffanie Watkins, on behalf of the Association of California Life and Health Insurance Companies. We too are in opposition today would echo many of my colleagues comments. We understand the sensitivity around this disease and look forward to having those future conversations and reviewing the amendments. As my colleague mentioned, the medical necessity standard is sort of the benchmark or rubric around how we design our healthcare products.

And we've continued to sort of want to work with and have that discussion about the importance of including that standard and would like to continue those conversations, especially in that broader discussion with the potential for a benchmark PAN and the evaluation of the HPS as these bills move forward this year. So thank you.

Any additional witnesses in opposition?

Madam Chair and members: John Winger, on behalf of America's Health Insurance Plans, would just echo the comments. CAHP and Acquisition. Look forward to future conversations.

Thank you. I'll bring it back to the committee for any questions or comments. Vice Chair.

Thank you. Madam Chair, I just want to say that, you know, we see so many times where early detection, early treatment can make such a big difference in the quality of life of people, especially young people. We want to make sure that, you know, we can intervene as quickly as possible.

A devastating illness like this is one of those that I think all of us agree needs to get the treatment as soon as possible. I want to thank the witnesses for coming forward. I know it's difficult testifying here, but we hear you, and I will be supporting the bill.

Thank you, and I also want to thank the author for your commitment to this disease and for putting forth language that will hopefully strengthen this bill and continue to bring awareness to PANDAS and PANS.

And I want to especially thank the coalition that I was able to meet with prior to this hearing to really help me to understand the true impact and the concerns that you have in terms of not being able to get timely treatment in a way that is helpful to you all. I also want to recognize that we are on both the senate side and assembly side going through a broader process.

And I mentioned this to you all that will look at the essential health benefits and know that that will be another opportunity, if you will, to be able to look at addressing treatments and conditions like this. With that, my recommendation for this bill is an aye. Assembly Member Lowenthal, would you like to close?

Yes. Thank you, Madam Chair and committee, I want to commend the families that came here today and the proponents of this bill that came to speak. It's a very emotional issue, and I also want to offer a hug to those in opposition. I can see how challenging it is and difficult it is for you to be on the opposite side of this. This is an issue, clearly that affects the families, but in truth, it affects all of us. We're all paying for not dealing with this.

These families have to utilize many of whom have to utilize state social safety net services because the onset is so acute and so debilitating that they have to leave their jobs right away to care for their children. They're ailing children for a process that will ultimately get approved. So there's a cost, a huge cost for us not dealing with this. I really, truly appreciate the consideration. Thank you, Madam Chair. And respectfully ask for your aye vote.

Thank you, Assembly Member Lowenthal. Do I have a motion? Moved by Aguilar-Curry, seconded by Doctor Arambula. With that secretary, please call the roll. It is do-pass as amended to Appropriations.

[Roll Call].

That measure is on call. It needs one more vote. Thank you.

We are going to move on now to item number 15. AB 2449 Ta Assembly Member, Ta Go Ahead and while your witnesses get situated.

Thank you Madam Chair and Member of the Committee. I want to thank the Committee staff for their hard work on the analysis and collaboration with my office. AB 2449 would clarify that the qualifier of live behavior Analysis Credential Board is a national entity that may certify a qualified autism service provider and underwriter certification to be accredited by the American National Standard Institute, also known as NSI.

The qualified Applied Behavior Analysis Board, or Huawei was established in 2012 and is in agencies whose mission is to establish a high standard of care and empower all professionals who provide behavioral health intervention services to individuals with autism. KaaBa is a second lecturer certifying body for applied behavior analysis in the US and the largest internationally. Huawei certification are integral to the provider community for individuals in state with large military population, many of which recognize Huawei for the licensing of autism service provider.

I would say is seen and observed in a number of children with autism result in a Shorter qualified autism service provider, particularly in Low income communities. AB 2449 seek to meet this shorted professional caregivers by adding an additional licensing organization that is recognized federal and worldwide for the high standard. This will effectively end California reliance on a single entity to provide all certification. By creating competition in the field.

AB 2449 would not only authorize ANSI to exist in the backfield of professional of the profession requiring state licensure and certification, but also provide a potential solution for people who report difficulty gaining employment with me to testify and support our holy Benny Gosa, the secretary rector of Cueba, and Beth Brooke, Executive Director of Autism Society Inland Empire.

I also like to mention that I have Warren Merkel, the Vice President of policy with ANSI and Juparsson with the autism behavior services to answer any additional technical questions.

Thank you. You'll each have two minutes.

Thank you. Madam Chair and Members of the Committee, I appreciate this opportunity to speak on the support of California AB 244449. My name is Holly Benincosa. I'm the Executive Director with the Qaba Credentialing Board. This Bill will create access to care and that is the biggest thing that we are looking for is access to care with individuals with autism. It is crucial for expanding access to the essential services.

Qaba's involvement will ensure a broader range of qualified providers addressing the growing demand for autism services across California. We do include an autism component in our coursework, which is so important to know who it is that you're working with. About 90% of cases involve, excuse me, applied behavior analysis is the science and it's predominantly applied to individuals with autism. It is important that these professionals have an understanding of who they're working with. And UC Santa Barbara actually is one of our coursework providers.

They are an accredited University, as you well know. Qaba has philanthropic endeavors where every. We are a for profit entity, but every penny goes back into the credentialing program. And this allows us for giving discounts to developing countries who have limited access to the care that they need. And with the CDC now reporting autism one in 22 in California alone, it is important that we have access to care. So in conclusion, I would like to thank you for your time and support. 2449.

Thank you. You'll have two minutes.

Thank you. Good afternoon, Madam Chair and Members of the Committee. And I'm going to try to do this without tears. So I'm going to try. My name is Beth Bird. I'm the Executive Director for the Autism Society Inland Empire. I'm the co chair of Autism Society of California Public Policy. More importantly, I'm a proud parent of two young men, one of whom has autism. About 25 years ago, it took our family six months to get services for my son.

He was three and a half when we began the journey. And as you can imagine, it's an emotional journey for anybody. And I was no different. But my emotion turned to crisis. My beautiful baby boy started raging for either 60 to 90 minutes every single day. And I'm not talking about a toddler's temper tantrum. I'm talking about he went full on attacking me, hitting, spitting, biting, pinching me so hard it left bruises all over my body.

I was sweating many, many days just trying to restrain him. And there's other days where I would have to hold him in his bedroom with the door shut and listening to him crying, screaming, and just completely out of control. And I didn't know what to do. Our family was in crisis, and I was in crisis coming out of COVID It is the same thing for these families. Now we're hearing that many parents are facing six months to 12 months wait times.

We're not talking about families that are just waiting for a Doctor's appointment. We're talking about families who can't communicate with their child. We're talking about families who have children like mine that are completely out of control and they feel alone. We're supporting this Bill because it's giving critical access to children and families right away, and that is sorely needed. I urge the Committee to pass this Bill so families that can begin their autism treatment as soon as possible and without having to go through the crisis. We did. Thank you.

Moved by Aguiar-Curry, seconded by Schiavo. Thank you. Are there any other witnesses in support?

Eric Linder, representing Qualified Applied Behavior Analysis in support.

Rick Rawlins, on behalf of the Autism Business Association and also a parent of a 34 year old son with autism.

Tyler Rinde, on behalf of the California Psychological Association, in support. Thank you.

Thank you. Any witnesses in opposition?

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

Okay. Good afternoon. My name is Matt McAlear from the California Association for Behavior Analysis. We are a nonprofit trade association representing providers of behavior analytics services in California. The critical issue we see with the bill is that the QABA certification does not meet the characteristics of licensing or certification programs currently in statute in California. The legislature has determined repeatedly that the practice of behavioral health profession independently, that is, without supervision, individuals must meet standards that have been developed by their respective professions.

These include an advanced degree from an accredited University, supervised experiential training, and passage of a professional examination that's both psychometrically and legally validated and comply with the code of ethics that has been developed by a nonprofit professional Association or credentialing entities in their respective professions. These legislative decisions are evidenced in the current state laws for licensed psychologists, clinical counselors, marriage and family therapists, and clinical social workers. The board-certified behavior analyst certification is recognized and codified in California statute as a qualification for practicing behavior analysis professionally.

The requirements for obtaining that certification mirror the requirements for obtaining licenses and other behavioral health professions in the state. In stark contrast, the QABA certification does not meet the licensing and certification programs of practice in California. The eligibility requirements, exam content administration, and ethics code are developed by a private, for-profit organization. No coursework from an accredited university is required.

Instead, courses for the QABA certification may be obtained from individuals or private companies that are approved solely by the private entity that owns and operates the certification program. The QABA certification is also specific to autism intervention and while needed, this is not a profession. None of the behavioral health professions regulated in California consider training and examination content that is limited to or focused on a single client population.

Adoption of this bill would put individuals within California and their families living with autism at risk and undermine the integrity of all behavioral health professions in the state. We urge a no vote on 2449.

Thank you. Go ahead.

Madam Chair, members of the Committee, my name is Mariel Fernandez. I'm the Vice President of Government Affairs for the Council for Autism Service Providers. CAASPP is a nonprofit trade association of Autism Service provider organizations that have a committed that are committed to promoting and delivering evidence based practices for individuals with autism. We represent 54 California-based organizations serving thousands of children and adults on the spectrum.

QABA and the QBA credential lack sufficient educational and experiential learning requirements to ensure competence in the practice of behavior analysis, knowledge in the scientific underpinnings of the study behavior, and sufficient safeguards to ensure competence to do no harm to some of California's most vulnerable citizens, children with autism. As you've heard, QABA is a for-profit entity, and there are potential disadvantages of for-profit credentialing entities, including lack of transparency and potential conflicts of interest. Ownership information is unavailable on the QABA website.

The American Board of Medical Specialties, the American Speech Language Hearing Association, the Association for Marital and Family Therapy Regulatory Boards, the American Board of Professional Psychologists, and the Behavior Analyst Certification Board are all nonprofit credentialing entities. The standard for professional credentialing is a nonprofit entity with transparent business practices, including governing practices and organizational structure. You've heard that the addition of the QBA Credential will increase access to care. There are currently a limited number of QBAs in California.

Of the 843 active QABA certificates, as of Monday, only 21 of those obtain a QBA. This issue has been heard in multiple states, including Texas, Georgia, Virginia, Nevada, Kansas, Washington, and Oregon, and each of these states has indicated that they will not modify to recognize the QBA. Thank you for your time and your service to the great State of California, and your commitment to protecting children and adults with autism. I respectfully request a nae vote.

Thank you. Are there any other witnesses in opposition? Please come forward. Seeing none, I'll bring it back to the committee for questions or comments. Mister Ta, you can close.

Yes, I'd like to. I'd like to thank the chair for her support on the bill. AB 2449 will expand access to services to the state's population that cannot access them due to the limited number of options for qualified autism service providers. AB 2449 is the next step toward helping families who have been impacted by autism. So, I humbly ask for your aye vote.

Thank you, and I just want to thank the author for his continued commitment to the issue of attempting to increase provider access to children with autism. Especially, it's clearly a passion and policy area focus for you. And with that, the motion is do-pass to Appropriations. Please call the roll.

[Roll Call].

That measure is on call. It needs three more votes. Thank you. We'll move forward with item number 17, AB 2490 Petrie-Norris. Please proceed when you're ready.

Thank you. Good afternoon, Madam Chair and members. I'm pleased to join you today to present AB 2490 to expand and improve access to reproductive care in emergency departments across the State of California. For many pregnant Californians, emergency rooms are the most accessible source of medical care due to a lack of health insurance and shortages of primary care providers, OB-GYNs reproductive health clinics. Unfortunately, too many emergency departments and their staff are underprepared to ensure patients get quality miscarriage, contraception, and abortion-related care. They just weren't trained for it. The result of all of this is that it puts some of our most vulnerable patients at increased risk. Some ERs have put together their own protocols to make sure their doctors are prepared for these scenarios, but in nowhere near adequate to meet the need.

AB 2490 establishes the Reproductive Health Emergency Preparedness program within the Department of Healthcare access to expand and improve reproductive health care in emergency rooms across the state. I'm pleased to be joined today by two witnesses, Doctor Kelly Quinley and Doctor Rakesh Saxena. Thank you.

Good afternoon, Madam Chair Members. My name is Monica Saxena. I am a practicing emergency physician and clinical assistant professor at Stanford University School of Medicine. I speak to you today in my personal capacity.

In March of 2022, my colleagues and I initiated a medication abortion protocol in the emergency department. To my knowledge, Stanford is the first emergency department in the country to do so. The impetus for the protocol is aligned with the ethos of emergency medicine. Any patient, any problem, any time. Emergency medicine physicians are not only the front line; we are often the first line, meaning we are the touch point for a patient's entry into the healthcare system.

This is especially true of pregnant persons; where of the 2.7 million pregnant persons who visit the emergency departments annually, 13% are not aware they are pregnant until they are in the emergency department. One reason Stanford is able to provide medication abortions for our patients is because of the emergency physicians' knowledge of the two drug medications used in abortion. These drugs, mifepristone and misoprostol, are routinely used in the treatment of miscarriages.

As an emergency medicine physician, I know the physiology of these drugs, how they work in the body, and their side effects. Clinically, providing abortions for my patients did not require me to augment my baseline medical knowledge. What was required was learning how to implement the protocol into the existing hospital system. As such, to implement the protocol took one and a half years. I am deeply proud of our efforts at Stanford and believe California patients should have more options than just the Stanford Emergency Department.

To receive reproductive health care in an emergency care setting. The financial and logistical support provided to emergency departments and AB 2490 would make providing medication abortion in the emergency department a reality for other hospitals and benefit the women of California. As an emergency medicine physician, I strongly support the bill. Thank you.

Thank you. I appreciate that.

Thank you. Hello, Madam Chair and committee members. My name is Kelly Quinley. I'm an emergency physician. I practice here in California.

I'm also a board member on the board of directors of the California chapter of the American College of Emergency Physicians, and I represent that organization in support of this bill as well. The Dobbs Supreme Court decision has greatly limited the availability of abortion related health care for many patients in this country. But another force that's restricting healthcare access in our system, where it's already difficult for many to access medical care, is the progressive closure of many labor and delivery units across the United States.

Now, in California alone, we have seen close to 50 hospitals close their labor and delivery program since 2012, and the majority of those closures have actually happened in the last three to four years. As these closures accelerate, they're leaving many of our most vulnerable patients with even less access to care.

And this means that for patients in California when they have a pregnancy-related medical need, whether it be before pregnancy, with contraception needs, early in pregnancy for an ectopic pregnancy or miscarriage, or later in pregnancy, the emergency department may provide the closest and or the only feasible access point to a medical provider. But labor and delivery closures mean that for many hospitals, there are no longer obstetricians in the hospital around the clock for in person consultations and procedures.

So, emergency physicians need to be prepared to provide this care. But they often lack the skills that are needed, as emergency medicine training has traditionally included some aspects of this care, but not all. For example, the minimum requirement for an emergency physician to graduate residency is to deliver ten babies only, which is woefully insufficient to replace services where l and d units have closed.

The creation of the Reproductive Health Emergency Preparedness Program would, on an opt-in basis for California Eds, fill in gaps in training and reconcile those with the needs of our patients, and would also help ensure that Californians are cared for in emergency departments, where their providers have knowledge of safe, effective, and evidence-based reproductive health care. In doing so, we hope to raise the standard of care that will be the model for other states to adopt as well. Thank you.

Thank you. Are there any other witnesses in support?

Ryan Spencer, on behalf of the American College of OB-GYNs, District Nine, in support.

Shannon Olivier Hovis with Reproductive Freedom for all California. We are a sponsor of the bill, in support.

Good afternoon. Bill Barcelona with America's Physician Groups, in support.

Hello. Angela De Silva, Women's Advisory Board, City of West Hollywood, in support.

Hello. Kim Robinson with Black Women for Wellness Action Project. Also, a co-sponsor and strong support. As well as Black Women for Wellness in support.

Hello. Alena Chavez with TEACH, also a co-sponsor of this bill and strong support.

Grace Glaser, on behalf of VALOR, in support.

Alexis Rodriguez for the California Medical Association in support.

Symphony Barbie, Planned Parenthood Affiliates of California, in support.

Thank you. Are there any witnesses in opposition? Seeing none. Bringing it back to the committee for questions or comments. Seeing none. Please close.

Thank you, Madam Chair. The goal of AB 2490 is to ensure that pregnant Californians in crisis are able to receive quality, comprehensive care, no matter what part of the state they live in and no matter their zip code. With that, I respectfully ask for your aye vote. Thank you.

Thank you. I appreciate that. We need a motion and a second. Oh, we have a motion. Motion by Agiuar-Curry, seconded by Schiavo. Thank you. Please call the roll. The motion is do-pass to Appropriations.

We're moving on to item number 21, AB 2859 Patterson.

Sorry about that. Well, thank you, Madam Chair and members; we will be accepting the committee amendments. Appreciate the work that the committee has done in proposing the amendments with respect to those that were requesting, ASME and our California Professional Firefighters. Appreciate both of those organizations, and we accept those committee amendments. AB 2859 builds on previous legislation. Public fire and law enforcement agencies are now authorized to establish peer support programs for their members to address a range of emotional and professional challenges.

But unfortunately, EMTs ambulance employees face similar challenges in their daily roles that may also impact their mental health. However, this is not adequately addressed by existing peer support programs, and that leads to a potential gap in both emotional and professional assistance for these critical first responders. Also, given the current staffing shortages seen across the state, the time and the need is obviously now to close this gap and to give them the sample help now offered to their fellow frontline safety professionals.

AB 2859 would enact a peer-to-peer support program for emergency medical technicians and ambulance employees. AB 2859 would offer comprehensive support for the emotional and professional challenges that they face while they are on duty, for us, and in very difficult and emotional circumstances. AB 2859 aims to enhance the overall well-being and the resilience of EMTs and ambulance staffers by fostering a new supported network within their own professional community.

This legislation is co-sponsored and has the support of the California Ambulance Association. It is also supported by the Emergency Medical Services Administrators Association of California and the EMS Directors Association of. California. And here with me to testify in support of AB 2859 are Shad Thomas, he's the manager of the Clinical Medical Health for Global Medical Response, and Katie Andrews, who is the EMS coordinator for Tuolumne County.

Madam Chair and members of this committee, thank you very much for this opportunity. My name is Shad Thomas.

I'm a licensed clinical social worker employed as the manager of clinical mental health by Global Medical Response, the parent company of American Medical Response and Reach, among others. My duties include providing peers with critical incident stress management training, support consultation through our peer teams nationally. I'm speaking on behalf of the California Ambulance Association. There's an overwhelming body of research demonstrating the positive outcomes associated with peer support and the services outlined in this bill.

In my professional opinion and personal experience, there is not a more effective, efficient intervention in reducing the potential impact of of new critical incidents and supporting the growth and healing that is possible coming out of previous events on groups and individuals. One of the most significant contributing factors to the known negative outcomes associated with critical incident stress in EMS is the fear that confidentiality will be broken, leading into negative changes in how coworkers view the individual and that there will be negative impacts on their career.

This belief contributes directly to more severe negative outcomes such as substance use and suicidal ideation. Many EMS professionals do not consider their professions just a paycheck but as a deep part of their personal identity. This means the fear associated with accessing support is not about losing their job but about losing the respect of their peers and a deep, important part of who they are. Easing the sphere will have a positive impact on the willingness to utilize support services and cause a positive shift in EMS culture.

Professionally, as an LCSW, and personally, as a combat veteran who has utilized similar services, I strongly voice my support for Assembly Bill 2859, and I respectfully recommend that you do the same. Thank you.

Good afternoon, Madam Chair and members of the committee. Two days from now marks the solemn two-year anniversary of a tragic event that shook our local EMS community to its core.

It was on this day that we lost one of our own, not to a physical injury in the line of duty, but to mental health struggles that so many of our emergency medical services face silently. This law spurred deep reflection on the challenges of our EMS, on the challenges our EMS professionals face both on the front lines and in private. My name is Katie Andrews, EMS coordinator for Tuolumne County and EMT for nearly 20 years.

I'm here today to urge each of you to vote yes on AB 2859 which addresses a significant gap in California law. Currently, our laws allow for and provide protections for law enforcement and fire personnel participating in peer support programs, recognizing the unique stresses that they encounter. However, our EMS professionals, who face similarly demanding situations, do not have the same level of support and protections.

Peer support programs have proven to be incredibly effective in providing a confidential and understanding environment for individuals to share their experiences, seek guidance, and access mental health resources. Peer support programs also enhance emotional resilience, reduce mental health stigma, and improve job satisfaction. By enacting this bill, we not only acknowledge the unique challenges faced by EMS professionals but also empower them to prioritize their mental health without fear of judgment or repercussions.

It is our duty to ensure they have the support and resources they need to navigate their own challenges. Let us honor the memory of my fallen colleague by standing together to pass AB 2859 and create a safer, healthier environment for all EMS professionals in our state. Thank you.

Thank you. Is there any additional witness and support?

Hi, Darby Kernan; on behalf of the Emergency Medical Services Administrators Association of California, MSAC, in support.

Thank you. Are there any witnesses in opposition?

Good afternoon, Chair and members. Janice O'Malley with the American Federation of State and County Municipal Employees here on behalf of our AFSCME United EMS Workers Local 4911. We were opposed unless amended on the bill. Wanted to express our gratitude and appreciation for accepting the Committee amendments that will then remove our opposition to the bill. There is absolutely value in peer-to-peer support for our EMS workers.

We just wanted to ensure that they had input on developing the program to ensure that it benefits all of them in a positive way. So thank you very much.

Thank you, Madam Chair and members. Doug Subers, on behalf of the California Professional Firefighters, we don't have a formal position on the bill but we would like to thank the committee and the author for accepting the amendments today and working with us. Thank you.

Thank you. Any additional witnesses in opposition? I'll bring it back to the Committee. Seeing no comment, I will just offer a thank you to the author for bringing forward this legislation. As you know, I shared recently a journeyman in memory for a fallen firefighter in my district, who is a friend, and certainly know from that experience that it's incredibly important that our first responders have the kind of support that they need. So, thank you for bringing this forward.

And I want to just thank the author as well for working with AFSCME and the firefighters to ensure that it's a holistic program that includes and integrates the needs of the workforce in a way and also ensures that there's no conflicting issue with the existing programs for firefighters in terms of peer support groups. With that, my recommendation is an aye. Please close.

I appreciate working with the committee, appreciate those who spoken. And we took those amendments. They were good-faith amendments. We appreciate the fact that we can have these kind of discussions. When you think about what these EMTs do, they show up at places where horror has happened, and they have to face it, and they have to make split-sentence decisions.

And as the mayor of Fresno for eight years, I saw what our EMTs did up close and personal, firsthand, and got to know a lot of them over my period and tenure. They deserve this kind of help and support. They're going to get it. And I'm grateful for the opportunity on their behalf to present this bill and ask for your support. Thank you.

Thank you. I need a motion. Motion by Waldron, seconded by Aguiar-Curry. Sorry, it came that way first. The motion is do-pass as amended to Judiciary. Please call the roll.

[Roll Call]

That measure is on call. It needs two more votes. Thank you.

We are going to move now to item number 24. Apologies to Assembly Member Gipson. Assembly Member Lee apparently has witnesses who need to be able to exit more swiftly and asked for a previous disposition on that. AB 2960, Assembly Member Lee.

All right, thank you, Chair and Members. Today I'm presenting AB 2960. The State of California is experiencing a meteoric rise in sexually transmitted disease infections of every kind, across genders and age groups, across race and ethnicity. But one that stands out is congenital syphilis, where a pregnant person with syphilis infects their fetus. Unlike other STIs, congenital syphilis too often leads to tragic outcome, a stillbirth or neonatal death. California has witnessed a 1500% increase in congenital syphilis over the past decade.

We have the 11th highest congenital syphilis rate in the country, and the rate in California is 63% higher than the national rate. We have failed to get ahead of the epidemic and turn it in a positive direction. Current law can be very impactful when mandatory testing and treatment of a pregnant person can ensure a healthy delivery in most cases. But according to the CDC, more than 10% of the cases that are identified and treated do not save the baby.

And aggravating the situation, at least 15% of pregnant persons are getting no or inadequate prenatal case and not getting tested and treated for syphilis. AB 2960 seeks to get ahead of the problem by offering a syphilis test to a person who can get pregnant before they get pregnant. It also will help to engage many persons who are pregnant but are not receiving adequate prenatal care.

Our approach to this epidemic must be more forceful, or we will continue to see a shameful rise in deaths caused by congenital syphilis. I have with me Dr. Jeffrey Klausner, a leading expert on STD prevention and control and a professor at USC's Keck School of Medicine, and Rand Martin on behalf of the AIDS Healthcare Foundation and the sponsor of the measure. Thank you.

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

Madam Chair and Members, hello. My name is Dr. Jeffrey Klausner. I'm a practicing internist and infectious disease physician, Professor of Medicine and Public Health at the Keck School of Medicine, University of Southern California. I'm here representing myself today. From 1995 to 2010, I served as a Public Health Officer responsible for syphilis prevention with the US CDC and the City and County of San Francisco, and have served as past President of the California STD Controllers Association.

I'm speaking in strong support of AB 2960, which would increase syphilis case finding among those who can become pregnant in California. Syphilis is very serious. Babies born with syphilis often die or are left with lifelong disability. In 2021, the California Department of Public Health reported 528 cases of newborn syphilis, a rise from only 33 in 2012. In that same period, early syphilis cases in females increased over 10 fold. Syphilis is highly preventable and treatable.

With a simple blood test and a shot of penicillin, in adults, syphilis can be cured. But not all pregnant people can be cured before spreading syphilis to their fetus. That's why we must find and treat syphilis in people before they become pregnant. In the 1950s, when the frequency of syphilis was about 10% in the general population, laws were put in place to ensure routine syphilis testing. Routine testing and treatment resulted in dramatic declines in syphilis over the next decade. We have a similar opportunity now to reduce syphilis and save babies lives by ensuring those at risk are offered voluntary testing. I urge you to support AB 2960 and help protect those most vulnerable.

Madam Chair and Members, Rand Martin on behalf of the AIDS Healthcare Foundation. I want to start by giving you a little history lesson about what AHF did 10 years ago, when the HIV epidemic was really on the rise. Every month or every year was going up and up and up and up.

We sponsored a bill that Holly Mitchell carried for us, AB 446, that mandated an offer of an HIV test at all public health clinics. That was enacted and went into effect in 2014. In 2014, we started to see those numbers start to come down. Now, we don't take ownership of that 100%, but we do know that that educational opportunity had a material effect on the ability of the state to get ahead of the HIV epidemic and turn the corner.

We believe that the same thing can happen with syphilis. We're particularly concerned about congenital syphilis. The reason this bill, for example, only addresses people who can become pregnant is because they're the ones who can pass on the syphilis to the fetus. So we wanted to get to that issue more importantly than any of the other STDs that are also out of control but also can be dealt with with treatment very effectively. I do want to point out that what the bill does does align with what public health generally says today about routine testing.

The Department of Public Health, in both its recommendations on syphilis screening and in its recommendations relative to testing in emergency departments, support very strongly the idea of routine opt-out testing for not only syphilis, but HIV and hepatitis C. This bill follows those guidelines, and we think that it will have the effect that we want it to have, as it did 10 years ago, 11 years ago, with HIV. We urge your aye vote. Thank you.

Thank you. Are there any other additional witnesses in support?

Chair and Members, Kathy Mossburg with Essential Access Health in support.

Thank you. Any witnesses in opposition?

It mandates that syphilis testing is offered on an annual basis to every single individual who may get pregnant, regardless of risk, indication, or clinical recommendations. Contrary to what was just said, this blanket approach can lead to unnecessary anxiety, potential stigma, and the diversion of time and limited healthcare resources for from higher risk populations who are in greater need of these services. As stated in the analysis, the Department of Public Health identifies these high risk individuals, such as those who are pregnant or sexually active or incarcerated in a certain area, and only a subset to be tested frequently.

Requiring health professionals to offer an annual medical procedure such as syphilis screening to individuals not based on clinical guidance can strain the relationship between a patient and their provider. I've heard the question, what is the harm in offering a test to someone who does not need it? One harm this, a patient having to wonder if a medical procedure is being offered due to medical necessity or critical judgment, or because the provider is required by law to do so, regardless of indication.

Even if you took existing clinical guidance and placed it in a statute, problems would still exist. New data may surface in the future that highlights new evidence-based approaches that targets a specific at risk population proven to lower syphilis infections. But unfortunately, if this law goes into effect and despite new clinical guidance, we would still need to dedicate viable resources to meet a specific requirement, even to those who may not need it.

This is not how science, medicine, innovations of public health should work. It should be evidenced and research-based and fluid. And unfortunately, as laudable as this intent may be, this is not the case with AB 2960. I ask for your aye vote... Ask for your no vote.

Tricky, tricky there.

I'll take that.

You'll have two minutes.

Good afternoon. Alexis Rodriguez of the California Medical Association, representing nearly 50,000 physicians and medical students across the state, in respectful opposition to AB 2960, Lee. Although CMA understands the intent of AB 2960 is to control and decrease the spread of syphilis, we must oppose the approach to require a syphilis test to be offered to any individual that can become pregnant, regardless of clinical guidance.

Per CDPH guidelines, syphilis testing is recommended to certain high risk groups, pregnant individuals being one of them. Implemented only a few years ago, SB 306 Pan ensures healthcare providers are able to provide syphilis screenings and testing with prenatal care in accordance with guidelines published by CDPH. These guidelines recommend all pregnant patients are screened twice during pregnancy, once in their first trimester and again in their third trimester.

The decision for a physician to offer a medical procedure, a procedure to their patient, should be based on the professional judgment of potential risk factors and through conversations with their patient. Mandating a physician to offer any sort of medical procedure could harm the patient physician relationship and potentially steer the conversation away from the initial reason the person sought care. These types of conversations have the ability to delay care and put an unnecessary burden on physicians and their patients. For these reasons, CMA is in respectful opposition and asks for a no vote. Thank you.

Other witnesses in opposition?

Thank you, Madam Chair and Members. David Gonzalez on behalf of America's Physician Groups, respectfully in opposition.

Madam Chair and Members, Tim Madden representing the California Chapter of the American College of Emergency Physicians. We have an opposed unless amended position and available to answer any questions if necessary.

Vanessa Gonzalez with the California Hospital Association, also with an opposed unless amended a position to remove the requirement for hospital emergency departments to provide the testing. Hospital emergency departments are experiencing high capacity and should continue to focus on emergency care. Thank you.

I will bring it back to the Committee for questions or comments. Dr. Weber.

Thank you, Chair. And hopefully you'll indulge me with these questions that I have because this, I think, is a very important issue. I want to thank the author and the sponsors for bringing this up, allowing us to have this discussion here today.

I think, or at least I hope, you know, everyone is very concerned with the rise in not only syphilis and congenital syphilis. And, you know, as an OBGYN, it is definitely something that we deal with here with testing when someone comes in for their initial prenatal visit and then once again at some point in their third trimester. But this bill is very problematic for me. A lot of concerns with it. The first is that you would test anyone who has the potential to get pregnant.

That essentially means anyone, once they start having their period, once they reach menarche. And as an OBGYN that specializes in pediatric and adolescent gynecology, it is not uncommon for me to have a patient as young as 9 or 10. We do not consider that precocious puberty anymore, but to come in with their period. And, you know, when the opposition was speaking about the doctor patient relationship, you all have no idea how many times...

It was very, it was very contentious between myself and a parent, when I wanted to discuss with that parent in private, or that child in private when they're 12, about certain things, or if I ask them or if I screen them, I mean, it's a, especially if that child didn't necessarily need it. And so I just want to highlight that that is truly the case.

If you don't see and manage pediatric and adolescent patients, then you don't understand sometimes the difficulty that you have when you bring these very adult questions into a space, into a child that may not even be there. And so this blanket, anybody who can get pregnant, is extremely concerning.

The other thing I found interesting in this is that you specifically call out a medicine to be used if penicillin isn't available, which I think is also problematic because you're putting that in statute, and yet that medication may not be as effective in the future. There may be another one that's better, and yet we would be passing into law a medication that we must use instead of using something that may be better in the future.

And I think that's also very problematic when we are talking about putting into law what physicians and healthcare practitioners should be deciding based on newer technology and evidence. I'm also concerned with a trend that we see with some of the legislation that we, as legislators overall, know more about what's going on in the healthcare space, in the science space, what the evidence shows than those who do this on a daily basis.

I would like to ask my fellow physician, because I could not find this, but you have been in this field for a very long time. Where is the study that shows that patients who had congenital syphilis or delivered a baby that had congenital syphilis had been seen by a healthcare provider here in California within a year, two years of them getting pregnant, they were at risk and did not get screened? I couldn't find that study.

All right, so the national data, which was reported by the CDC in a report called Vital Signs showed that about half of women who had syphilis and delivered a baby with congenital syphilis were seen in the emergency room. And, you know, very few sought prenatal care. So I think that's why the authors added emergency room venues as a place to meet. I mean, I think we recognize they're important social determinants of health, and we'd all love to be able to address those social determinants, but we have to be practical and we have to respond to the crisis now.

Right. I completely understand that there's a reason why, and I'm sure you're aware, we within the healthcare space have moved from just a blanket, I'm going to do this for everybody, to something that's more an evidence based approach. I am also kind of guilty, when people come in, I'd love to just order every single test just to ease my peace of mind. But there is a reason why we have an evidence-based approach.

And so I wasn't able to find any studies, specifically here in California, that show that patients who deliver a child with congenital syphilis had the opportunity to be seen by a healthcare provider prior to that pregnancy, they were at risk and were not screened. Because that's essentially what we're trying to get at. Right? And that's essentially what this bill is stating, screen everybody before they get pregnant. And I haven't seen any evidence that if we do that that that would ultimately change the outcome.

Essentially, I haven't seen evidence that says that the people who are delivering babies with congenital syphilis see healthcare providers prior to them getting pregnant. So that's a concern because we're moving away from what evidence shows versus not. But I do want to look at the evidence and, actually, CDC, someone had talked about recommendations. CDC recommends, of course, screening of all pregnant people and taking an individual risk based approach to syphilis screening for others. And Healthy People Goal of 2030 looks at reducing the rate.

And that if you have a rate of 4.6 per 100,000, then you need to do that risk based screening of ages like 15 to 44. So what do you think, here in California, the counties of Alpine, Colusa, Inyo, Lassen, Modoc, excuse me if I'm saying these wrong. Plumas, San Benito, and Sierra have in common? Their incident rate of primary or secondary syphilis between those between 15 and 44 is zero. Zero.

But what this bill would be saying is that we must go into those counties too and test everybody, even though there's no evidence that we should be doing that. You know, I'm very concerned, again, with moving away from evidence-based to just screening everybody. And I also just want to point out that the counties here in California that have a 4.6 per 100,000 primary syphilis rate or higher, they are screening people who actually come to see physicians per the CDC website.

And so, you know, unfortunately, I don't see any evidence that these individuals who have these children are getting care prior to their pregnancy and just not being screened. I don't see any rationale why we should go against, like, medical guidance, national guidance, national recommendations. I really respect what you are trying to do, Assembly Member Lee, but, unfortunately, I will not be able to support this bill today. Thank you.

Would you like to respond at all, Assembly Member Lee?

Sure. You know, thank you for your comment. You rightly identified that there are about 10 plus health jurisdictions in the State of California of the 61 health jurisdictions that have a low or absent rate of syphilis. But that leaves the 45 other health jurisdictions with all residents in those health jurisdictions of the 45 defined by the California Department of Public Health at increased risk. Both the United States Preventive Services Task force recommends that people at increased risk receive syphilis testing.

The California Department of Public Health recommends people with increased risk receive syphilis testing, and the CDC, of which I sit on the guidelines for syphilis recommendations, recommends those at increased risk. So the residents in the 45 health jurisdictions out of the 61 are indeed an increased risk. And we take a public health approach, which means, you know, sometimes we look at the entire population and the wellness of the entire population of California residents to make policy recommendations.

I thank you for that. And I respectfully disagree. I don't think that a nine year old or a 10 year old who is menarchal, who happens to live in a city with an increased risk, is at increased risk just because they happen to live there if they've never been sexually active, not even thinking of sexual activity. And, again, those counties that you mentioned are doing the individual risk based assessment that the CDC recommends. Thank you.

Ms. Schiavo.

I share some of the concerns, especially around testing kids. I have one of them, an 11 year old, and I can see how uncomfortable and awkward that would be with parents of young children, especially as periods are starting younger and younger amongst our girls. So I hope that there can be some consideration and discussion around this and the appropriateness of this. I think that would make a lot of sense. And also understanding how busy and overwhelmed our ERs are.

I hear what you're saying around the ERs being where some people get their healthcare, right. And obviously we're doing a lot to try to help address that so that that's not happening. Because we know it's the most expensive form of healthcare we could be providing and it's not particularly effective long term. So, you know, so I have reservations about that piece as well. I'm, where, I'm sorry, I don't know, but where is this going after this?

It's going to Approps.

Okay. You know, I do think the bill needs some work, and I will give a courtesy vote here today to allow that to continue and those discussions to continue, and reserve my vote for the floor, depending on how it moves forward. Thank you.

I want to... Oh, Ms. Carrillo.

Thank you, Madam Chair. I too would like to align my comments with that of my colleague and, who is a OBGYN, and several concerns related to the implementation of the policy, but even more concern related to bias and stigma for young girls, women, and people who can get pregnant. And I think if the issue is that there's a rise in syphilis, I would prefer to see policy that's related to information for anyone of any gender to have access to STD education.

And while it may currently exist, I think there could be more done. And so I just, I find it problematic that we put the onus only on young girls, women, and individuals who can get pregnant. And I just have a fundamental disagreement with any health policy that does that. And I think in previous issues related to HIV, AIDS, and other STDs, we have seen that that has happened in the past, and I would not like to repeat it.

I do believe that there is very good intention towards the bill, but I'm not sure that this is the right approach. And I would certainly, again, I'll just say again, I would like to see all individuals, regardless of gender, be held to the same standard when it comes to a rise in STDs, specifically with syphilis.

Mr. Jones-Sawyer.

And as you probably can tell, there's a lot of reticence, and there was a lot of information. I'm glad you brought it to this Committee because it is a concern, and it's something that we need to work on. And then sometimes in some of these bills, the methodology or the particular public policy that is brought before us may not be the correct way to move on this.

And sometimes we give a courtesy vote so that you can work on it, so that you can massage it, so we can get it to a point where, not only do you get to a comfort level, but I think you're going to have to go a little bit further with some of the Members here to prove that the methodology that you're using is the right one because you're going to need some backup. And I, too, share some of the same concerns.

I think what we would like to do, some of us will like to give you a courtesy vote here, but reserve, as you heard, you're probably hearing more and more now, wanna reserve our vote later, especially if it gets out of Appropriations, for the floor to see if it gets to a point where everybody's a lot more comfortable, and we believe that this is the correct way to move forward.

And so you will have a courtesy vote from me today, and hopefully you'll be able to work on this and talk to the professionals and especially people who've had a plethora of experience in this that sit on this Committee that you can talk to and help you get it to a point where it'll make sense to everyone to vote for it later on.

I'll just add these comments. So in California, California's had 528 cases of congenital syphilis in 2021. So 528 babies. We know that that's kind of a critical mass where disease is being passed from mother to child in record proportion numbers. So this is obviously, you know, there's a lot of passion around this, and there's also a need to be able to address what I believe to be a true syphilis crisis. I think what you've heard from the Committee comments is that there are aspects of this bill that are far reaching and perhaps too broad.

And, you know, there is something to say about the fact, and this is a part of the analysis, that there are people, birthing people and women, who are going to the ED for the first time, who are not getting the kind of prenatal care that they need to seen for the first time as they are able to present themselves in the ED departments.

I will be supporting this bill right now, but I think you've heard very clearly from the Committee that it would make a lot of sense to, as this moves forward, should it move forward out of this Committee, to focus and take amendments that allow for a severe narrowing around this and also to address the kind of the gender parity issues and, quite frankly, not targeting one particular group in this.

I'd feel greatly more comfortable with this bill if it focused particularly around people who are presenting as already pregnant, who had a need to be, and who were presenting, who had not received prenatal care prior to their visit in the ED. So I believe, I know that you work your bills. I believe, author, and I trust you, that you will continue to work on this bill should it pass out of the Committee. And for those reasons, I am giving a recommendation of aye right now and hope that we have an opportunity to continue to work on this bill given the incredible crisis that we're facing right now. With that, would you like to close?

Yes. Thank you, Madam Chair, and I appreciate your aye recommendation today and your flexibility for my witness. I just want to say that I appreciate all the comments today and the discussion in the Committee, and I especially appreciate Dr. Weber's lived experiences, of course, as an OBGYN. But to put into context, I want to reiterate what my witness talked about is this is a public health crisis, right? Syphilis is basically like a 17th century disease that is very curable and very treatable in this day and age.

But yet, even on your front page of analysis, in the last 10 years, syphilis has increased 287%. Now, I'm not a doctor, but I am the only Legislator who's under 30 years old, and I'm within that younger category that we're worried about. And, you know, the one thing that really pervades why it's, why STD is really why they can proliferate and why they can be so successful, is because young people, especially even in my group, without evidence, believe we are invincible, believe we have no diseases whatsoever. And I agree with Assembly Carrillo. I think it should apply to more people broadly speaking. But I don't know if my opposition will like that, but I think it should apply to more people more broadly.

But the enemy of public health and the proliferation of STIs is that people walk around without ever being tested, assuming that they never have these diseases. Now, this bill is narrow for a lot of feedback reasons to be focused on congenital syphilis, that really terrible phenomenon where a parent can pass it on to their fetus, and it might be too late for that fetus. The parent might be saved and they be able to, obviously, recover from that, but it might be too late for the baby.

And that's why we wanted to focus on that aspect. And congenital syphilis itself has increased 1500%. And again, stressing this is a disease from like, the medieval times, and that we have so much medicine to treat that. But this is on the rise with so many other diseases, and I believe that a robust system of testing that can be really universal as best as possible is the best way to decrease that stigma.

Now, we all live through a public health crisis where we easily were able to spread COVID to each other because, simply, we thought we did not have it as well. And so I'm really committed to continue working this bill. I think we can work on legislation, to Dr. Weber's point, about narrowing it to sexually active individuals, if that is more appropriate.

But we really do need to address this alarming rise in syphilis and make sure that it is not passed unwittingly onto a baby who might have very few options. But respectfully ask your aye vote today, and I appreciate all the comments today in the Committee.

I just also want to highlight, you triggered another thought in your close, the comment that Dr. Weber made about ensuring that we're not putting into statute a particular type of treatment I think is very well taken and needs to be reviewed as well in your as you continue, should you get out of this Committee.

Duly noted. Thank you, Madam Chair.

Thank you. With that, do we have a motion? Moved by Schiavo, seconded by Jones-Sawyer. The motion is do pass as amended... Just do pass to Appropriations. Please call the roll.

[Roll Call]

That motion is on call. It needs five more votes. Mr. Gipson, item number 20, AB 2775.

Moved by Waldron, seconded by Doctor Weber.

I think you know what that means.

Thank you very much.

I absolutely do know what that means. Thank you very much for allowing me to present Assembly Bill 2775, which seeks to clarify the EMSA's authority to develop guidelines surrounding telemedicine. With me to provide supporting testimony is Doug Shuber, a representative from the California Professional Firefighters, and also Tim Madden, representing the California Emergency Room Physicians.

Thank you, Chairman and members. Tim Madden, representing the California chapter of the American College of Emergency Physicians, co-sponsor of AB 2775. Make this brief. As mentioned, AB 2775 continues to build on California's commitment to providing safe, high-quality community paramedicine services by clarifying the Emergency Medical Service authority's authority to develop guidelines surrounding telemedicine, including considering data collection systems used in community paramedicine. With these guidelines in place, the utilization of telemedicine would operate under consistent guidance across systems, improving access to care.

For these reasons, we respectfully ask for your aye vote.

Thank you, Madam Chair and members. Doug Subers, on behalf of the California Professional Firefighters, pleased to be here as a cosponsor of AB 2775. I would like to thank Mister Gipson for his leadership on these issues. CPF is proud to have worked on innovation in the prehospital care space that tries to connect patients with the right care at the right time.

We think as long as we'd like to continue to work on innovation in this space, but innovation that is patient-centered, and for those reasons, we would ask for your aye vote. Thank you.

Thank you. Any other witnesses in support?

Elaine Batchelor, MLK Community Healthcare, in support.

Any witnesses in opposition? Seeing none. I'll bring it back to the committee for comment or question. Mister Gipson, you may close.

Respectfully ask what I vote. Thank you.

Thank you. Can I have a motion for this bill? Did we do that already? So sorry. With that, thank you, Mister Gipson, for bringing forward this very important bill for us, and secretary, please call the roll. The motion is do-pass to Appropriations.

[Roll Call]

That measures on call and needs three more votes. Thank you for your patience, Mr. Gipson. We will move on to Item number 23, AB 2956 Boerner.

Good afternoon, Chair and Members. Thank you for the Chair and the Committee staff for working with us on this Bill. I want to start by accepting the Committee's amendments. AB 2956 would adopt a 12 month continuous eligibility for adults and preserve federal flexibilities to Medi-Cal to prevent procedural disenrollments. Hundreds of thousands of Californians are experiencing gaps in their healthcare due to Medi-Cal's current disenrollment process. This is really unacceptable.

During the pandemic, California stepped up by adopting many federal flexibilities to remove unnecessary barriers to make sure people on Medi-Cal were covered. It had a positive effect on our health care system, relieving administrative costs and time. Since the public health emergency was listed, over a million Californians have been losing access to medical coverage in the first six months following the unwinding period.

I know we are navigating an incredibly difficult budget year, but we should not have to wait for another public health emergency to fix our current Medi-Cal enrollment process. California has the highest disenrollment rate at 92% over simple clerical errors. According to the California Department of Healthcare Services, 200,000 Californians were dropped from Medi-Cal in September 2023 for lacking necessary paperwork despite being still being eligible for coverage.

These are families who cannot go to the doctor for checkups and health services simply for a typo or lacking a piece of paper. California needs this Bill because we shouldn't have to wait for another public health emergency to make sure people are covered by Medi-Cal. We should do it now. We should. I respectfully ask for an aye vote. And I have here with me Whitney Francis with the Western Center on Law and Poverty, and Paola Ilescas with the Latino Coalition for a Healthy California, two co-sponsors of this Bill.

Aguiar-Curry moves the Bill, seconded by Carrillo. Thank you. You'll each have two minutes.

Good afternoon. Chairs and Members of the Committee. Thank you. I'm Paola Ilescas, Senior Program Manager with Latino Coalition for a Healthy California. Our mission is to advance and protect Latina health through policy and advocacy to build healthy communities in California. And this is including through our Pasa Lavos Program, where our statewide network of promotores coordinate community conversations in eight different regions across California, including San Diego, Los Angeles, Central Coast, Central Valley, Bay Area, and Sacramento.

Our promotores provide up-to-date health information to communities across the state in culturally informed and linguistically component ways on important updates regarding ITIN, P-EBT, and Medi-Cal. Medi-Cal program is a safety net program that provides healthcare across access to millions of low-income Californians. Unfortunately, since the unwinding process began last year, the disenrollment rates of Latina communities have been averaging nearly 50% on a monthly basis, and the majority are non-English speaking populations. The reality of this is shocking.

We've heard in San Diego women that they have shared that they have had to endure pain for weeks because they have been unable to see their OB-GYN due to being suddenly disenrolled in Medi-Cal. In Orange County, people with asthmatic conditions are looking for alternatives to their usual medications, which are thousands of dollars and while they're waiting to be redetermined eligible. And in Central Coast, many Mesoamerican Indigenous communities cannot find help in their language.

The system to navigate Medi-Cal enrollment is already difficult, and the disenrollment process is only another barrier. AB 2956 has solutions to ease this crisis and diminish interruptions and continuity of care. Healthcare services are crucial to one's life, and any disruption threatens well-being. By enacting AB 2956, it ensures people who are still eligible for Medi-Cal are not wrongfully terminated. I respectfully ask for your aye vote for AB 2956. Thank you.

Good afternoon, Chair and Members. Whitney Francis with the Western Center on Law and Poverty, proud co-sponsor of AB 2956, which would ensure Medi-Cal members keep their healthcare coverage by adopting a 12 month continuous eligibility for adults and making current federal unwinding flexibilities permanent. Each month, tens of thousands of low-income Californians are being cut from their Medi-Cal benefits, even when they are likely still eligible for Medi-Cal.

Over 80% of Medi-Cal disenrollments are for procedural reasons, meaning people are being disenrolled for missing paperwork, rather than being disenrolled because the county found them ineligible. Procedural disenrollments in Medi-Cal result in eligible people cycling on and off the program. This results in gaps in healthcare coverage and can lead to delays in care, including postponed doctor's visits or missed prescription refills. Enrollees of color, particularly Latinx enrollees, are disproportionately disenrolled due to procedural barriers, making AB 2596 a matter of health equity.

While many Medi-Cal members continue to lose coverage each month, federal flexibilities have increased automatic renewals and reduced procedural disenrollments. The federal unwinding flexibilities are scheduled to expire at the end of this year. If we let these flexibilities expire, it will be more difficult to bring them back and the gains in automatic renewals will be lost. This Bill would ensure that Californians can keep their Medi-Cal coverage without burdensome administrative barriers. This Bill would also continue improvements to county workflows and reduce workloads for renewal processing.

This Bill has no opposition. We urge your aye vote to safeguard Medi-Cal coverage for Californians. Thank you.

Thank you. Are there other witnesses in support?

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

Angela Vasquez with the Children's Partnership, co-sponsor in strong support. Thank you.

Mark Farouk, California Hospital Association in support.

Erin Taylor, on behalf of the California Dental Association and support.

Symphoni Barbee, on behalf of Planned Parenthood Affiliates of California in support.

Kelly Brooks, on behalf of the Santa Clara County Board of Supervisors, in support.

Hi. Darby Kernan, on behalf of the Local Health Plans of California and Leading Age California, in support.

Kim Lewis, on behalf of the California Coalition for Youth and Children Now in support.

Christine Smith, Health Access, in support.

Mar Velez with the Latino Coalition for a Healthy California, co-sponsor in strong support.

Onyemma Obiekea with Black Women for Wellness Action Project in support.

Matt Lege with SEIU California in support.

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

Thank you. Any witnesses in opposition? Seeing none, I will bring it back to the Committee for a comment or question. I want to thank the author for bringing forward this Bill. I think nothing good came out of COVID, nothing but the reality that it highlighted an opportunity for us to be able to create some flexibilities in our ongoing coverage of care so that people wouldn't get lost.

I really appreciate the witnesses in your testimony expressing that is one thing that we can at least have some solve around. So I want to thank the author for bringing forward this very thoughtful Bill and kind of finding the sweet spot of hope within our Medi-Cal enrollment system today. If you're open to it, I would love to be added as a co-author. With that, I think we have a motion in a second, and ask the Secretary to call the roll.

Oh, would you like to close?

I would love to add you as a co-author and respectfully ask for your aye vote.

Thank you. It's do pass as amended to Appropriations.

[Roll Call]

That measure's on call. It needs four more votes. Thank you. We will move on to item 30, AB 3275, Soria. Waldron moves. Jones-Sawyer seconds. Please go ahead. Put your mic on.

Chair and Members, thank you for the opportunity to present this bill. I want to take the time to thank the Chair and her staff for working on this bill. I also accept the Committee amendments noted in the analysis. The Speaker and I introduced this bill because we know that many small and rural hospitals are desperate to be paid on time for the services they provide to patients. Often, these hospitals are the safety net providers or the providers of last resort in many struggling rural communities.

In California, nine rural hospitals have closed since 2005, and 16 hospitals are currently at risk of closing. Financial distress is the main reason for these closed or at risk hospitals. To these providers in the battle to remain open, every penny counts. AB 3275 is a narrow bill that shortens the existing timeframe for health plans to pay clean and uncontested claims submitted by small and rural critical access and distressed providers to 10 business days.

In California, there are 37 critical access hospitals, 16 distressed hospitals, and about 25 to 30 that are likely to qualify under the small and rural definition. We're also asking Department of Managed Health Care to come up with a list of services to be paid in five days after receipt of a claim as long as the provider can document that care was provided. Current law requires health plans to pay providers' uncontested claims within 30 or 45 days. However, some health plans are not meeting this legal obligation.

Members, as you may be aware, Madera Community Hospital in my district was forced to close its doors in December of 2022 after providing healthcare services to the community for over 50 years. The impact to the community has been devastating. In the Speaker's district, his distress hospital had $4 million in outstanding claims against a health plan from August to December of 2022.

These practices are simply not sustainable, and I believe the timelines in this bill will mutually be beneficial to both parties, small and rural providers to submit completed claims and health plans to pay these claims sooner. With me today to testify in support of AB 3275 is Karen Paolinelli, CEO of Madera Community Hospital, and then we also have Dr. Elaine Batchlor of CEO Martin Luther King Jr. Community Hospital in Los Angeles.

Go ahead. Put your mic on.

Thank you. Good afternoon, Chair and Members. Thank you for allowing me to speak here today, and special thanks to Assemblywoman Soria for authoring this bill. My name, again, is Karen Paolinelli. I am the CEO for Madera Community Hospital. As many of you already know that Madera Community Hospital closed its doors back in December of 2022. Historically, Madera Hospital had been in operations for 51 years, and although we survived as an independent hospital for 51 years, it was not without challenges.

And when COVID came around in 2020, it took a toll on the hospital's financials. Today, I'm going to focus on the financial challenges Madera faced in regards to low reimbursement and timeliness of payments. Sorry about that. One of the most critical challenges Madera faced prior to our closure of the hospital was the ongoing issues with the reimbursement of healthcare claims. Our largest payers were HMO Medi-Cals, Medicare, and HMO Medicare Advantage plans. Madera had a huge problem with timely payments.

In some cases, it would take up to six months for us to get paid. And even when we did finally get reimbursement, the overhead required for the patients to have a service and the hospital to get paid was very costly. The reimbursement to hospitals by payers was not adequate to cover the cost of services that we were providing.

Our hospital, like many other hospitals, uses primarily uses an electronic billing system, and one might assume that a clean bill without any errors would straightforwardly result in a timely payment. Unfortunately, this is far from reality. Historically, even with clean submissions, at least 30% of our billing claims required some additional attention and manual intervention by our staff. This inefficiency in the billing process not only strained our administrative resources, but it also delayed the flow of crucial funds necessary to our operations. When a hospital gets a denial, it is costly for the hospital.

It takes a highly paid RN, physician, in some cases an attorney, to assist the hospital in writing an appeal. This can present a potential significant financial loss of tens of thousands of dollars to the hospital. Another common practice of payers is retracting payments, which is a process where an insurance company requests and reviews medical records. Okay, I'm sorry. Can I... Can I just get a couple... 30 seconds more. As you can see... Okay, let me try... I just want to say...

I want to say that I want this Committee to understand that Madera Community Hospital suffered greatly over the years due to inadequate reimbursement, delays in payment or payer inefficiencies, and a telling example of the consequences of these inadequate reimbursements was seen in the recent closure of Madera Community Hospital and struggles of hospitals that serve a high percentage of Medi-Cal payments. Madera...

Thank you so much. We're... Our past hour. Two minute mark. Appreciate it. Are there any other witnesses in support?

Good afternoon. I'm Dr. Elaine Batchlor, CEO of MLK Community Hospital and Health System. Thank you for giving me the opportunity to speak in support of AB 3275. MLK Community Hospital is a private hospital serving a public mission. We were created to serve the historically underserved community of South Los Angeles following the closure of King/Drew Medical Center, built as a response to the 1965 Watts Riots.

We operate today with a five star quality rating from the Center for Medicare and Medicaid Services and an A rating for patient safety. Our hospital's patient population is 60% Latino and 40% African American, and 96% of our patients are publicly insured or uninsured. Because we are underpaid for these patients, our hospital is in serious financial distress. Payment practices of managed care plans, from delayed authorizations to denial of claims to delays in claims payment, exacerbate our financial challenges. In 2022, we lost 23 million.

In 2023, we lost 41 million, and we could lose $26 million this fiscal year. We received a Distressed Hospital Loan payment to help us keep our hospital open through this winter. I want to emphasize to the Committee that expediting payments from health plans would support us financially and is a step in the right direction. And for that reason, we are pleased to support AB 3275. Thank you.

Thank you. Additional witnesses in support?

Good afternoon, Madam Chair and Members. Connie Delgado on behalf of the District Hospital Leadership Forum in support.

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

Dylan Elliott on behalf of the California Medical Association in support. Thank you.

Pat Whalen, Ellison Wilson Advocacy, here on behalf of UNAC Union of Health Care Professionals in support.

Mark Farouk on behalf of the California Hospital Association in support.

Nicette Short on behalf of Adventist Health in support.

Good afternoon. Beth Malinowski with SEIU California in support.

Good afternoon. Steve Stark on behalf of American Advanced Management Incorporated in support.

Are there any witnesses in opposition?

You'll have two minutes each.

Thank you. Good afternoon, Madam Chair, Members of the Committee, Jedd Hampton, with California Association of Health Plans here regrettably in opposition to AB 3275. I would like to thank the officer and her staff, as well as the Committee, for engaging with us on this bill. I want to start by saying that Health Plans have a vested interest in making sure hospitals stay operational so they can continue to provide the quality care to all the patients that we serve.

Health Plans have and will continue to do our part to help out even the most distressed hospitals. One specific way Health Plans have done this is by establishing contractual relationships with hospitals to serve our enrollees when they need these vital services. California hospitals receive billions of dollars every month from health plans, regardless of patient volume, through capitated arrangements. The arrangements are voluntary contracts where the health plan makes periodic payments to providers.

These payments are not tied to patient volume and provide an important funding source for keeping hospitals operating. Additionally, Health Plans also recently supported the reauthorization of the managed care organization tax, a tax that falls directly on our members to improve the MediCal program through a variety of rate increases for MediCal providers.

The distressed hospital loan program, which provides relief with interest free loans to not for profit in public hospitals, received $150 million of this money, in addition to the $300 million in General Fund spending that they had already received through the General Fund.

So, regrettably, AB 3275, from our perspective, ignores all of the work that California Health Plans have done to help out these financially distressed hospitals and instead proposes a series of measures that we believe will not solve the problem that this Bill is intending to solve. Specifically, AB 3275 reduces dramatically the amount of time the health plans have to adjudicate and pay claims.

Despite the robust regulatory framework that is already in place around timely payment of hospitals, Health Plans already have a specified amount of time to reimburse providers, and if we fail to pay a claim on time, 95% of the time, within that statutory framework, we are subject to interest, financial penalty, penalties, and enforcement against the plan. So, in closing, this bill creates a complex new process for educating and paying claims that we do not believe will solve the intended purpose of this bill.

And for these reasons, we are respectfully opposed. Thank you.

Madam Chair Members Steffanie Watkins on behalf of the Association of California Life and Health Insurance Companies, we, too, are here in opposition today. I mean, I think all of us do understand the importance and the role that hospitals play within the healthcare system.

They're a critical part of our system and one that I think all of us would like to have a conversation going forward about the possibility of how we can participate and continue to look at ways to be thoughtful about how the payment structure works. Unfortunately, the way the bill is drafted today, given the creation of a bifurcated system, the IT upgrades that would be necessary.

If you really look at how broad the bill is, it looks to not only the hospitals, but all the providers who have admitting rights within those hospitals would also be declared to be distressed and therefore then the timeframes would have to be in place. We think that there may be a pathway forward to have additional conversations. I think we all, like I mentioned, see the importance of the hospital systems within our healthcare system and how critical they are.

Unfortunately, the way this bill is drafted, we think that the costly nature of it, especially the complications of a new it system, and how you would bifurcate those systems in payment process provide a lot of concern for our members. So for those reasons, we are opposed. If the bill does move forward today, we look forward to future conversations.

Thank you Chair and Members Kathy Mossberg with the Local Health Plans of California. Unfortunately, we are opposed as well, but open to conversations moving forward.

Any other additional witnesses in opposition? Seeing none, I will bring it back to the Committee for comment or question. Mr. Jones-Sawyer.

I'll just say it might be because I probably am speaking for my colleague, Assemblymember Gibson, who's very familiar with Martin Luther King and the excellent work that Doctor Batchelor is doing, really trying to provide services to an underserved community. And they've done an exemplary job at doing that, to a point that they're overwhelmed with the number of people that are coming in, which is far beyond what they had anticipated.

When then, I think Mark Rilley Thomas had worked to reposition the hospital in a way that they could be an asset to community. Martin Luther King has always been there to take care of those who couldn't take care of themselves, who couldn't financially take care of themselves in distressed medical situations. To lose them or to have them go under in Watts in South Central Los Angeles would be catastrophic.

And we need to do whatever we can to ensure that not only her hospital but and others are able to stay afloat. Because if we don't, the underserved in those communities, if you think the medical care is bad in those districts now, God knows what it would be like without them.

And so not only do we need to look at ways we can make sure we can get some kind of economic financial relief this way, but we also probably need to look at some other options too. With the MediCal and Medicare, we need to look at them all because we need to reposition how that was done. And I believe we've talked about some ways to do that.

This is just one of them, and we need to move forward, and we need to do that as soon as possible, because the last thing we need to have is for any of these doors to close. I mean, you have no. I mean, we just can't have that happen. And so I will be voting for this today.

We'll make it quick. Thank you very much for bringing this forward. I'd like to be the co-author. I, too, had the same issues back in 2018. We were trying to make sure on how the repayment schedules were being done. I believe there's an audit done. And it just sparked me that I need to find out if that that bill was implemented correctly back in from 2018. So I appreciate the bill. Our rural communities always are just struggling.

And I don't know about you, but I like to be paid on time to be able to do this job. So I would only imagine that the hospitals won't be paid on time as well. So thank you.

I know that the author is deeply passionate about this. You are chairing a Select Committee on distressed hospitals. You have, Madera, the California Legislative Black Caucus also heard from the MLK hospital as well. And we know that our hospitals, particularly our rural hospitals, are suffering right now.

So I appreciate the author's focus and intention in bringing this bill forward. Thank you for meeting with me and looking over some of the concerns that I had about the bill, which really relates to whether or not this focus on delayed claims and the timetable set around that are going to result in the intended consequences that I know that you're hoping for.

So I know that you will continue to work on this bill with the opponents to try to get to a place where we know the intention is also achievable in terms of passage. And obviously, this is a jointly authored bill by the Speaker of the Assembly. With that, my recommendation is an aye vote and you may close.

Thank you, Chair, for those comments. Just in closing, I want to thank all of you, first of all, because last year, you guys were incredible in making sure that we did ensure that MLK didn't close in other hospitals across the state, that Madeira will reopen. And I would be remiss if I didn't also show my appreciation to the health plans as stated and acknowledge the support that they've provided also through the managed care organization text which they spoke about.

So I do want to show my appreciation. Obviously, there is a lot of work to be done around distressed hospitals and healthcare access in our communities and in the State of California. And so I look forward to continuing the conversations, to meeting with the stakeholders to make sure that what comes out in this piece of legislation is with the intended goal to ensure that hospitals continue to provide the critical services and that the timelines are realistic and achievable. As you mentioned, Chairwoman.

So looking forward to the continued conversation and I respectfully ask for an aye vote.

Thank you. The motion is do pass as amended to Appropes. Please call the roll.