Assembly Standing Committee on Health

Good afternoon. We'll call the California State Assembly Health Committee. Assembly Health Committee hearing for Tuesday, June 18 to order. 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.

Additional testimony is limited to name, position and organization. If you represent one for today's hearing, only assemblymember Jackson will substitute for Assemblymember Wendy Carrillo. Today's consent calendar includes the following bills proposed for consent. Any Member of the Committee may remove a Bill from consent. Item five, SB 963 item 13, SB 1319 Wahab.

Item 14, SB 1333, Eggman item 15, SB 1382, glacier item 16, SB 1397, Eggman in addition, removed from today's calendar is item 10, SB 1238, which we will not be hearing at today's hearing. With that, we are waiting for both Committee Members and authors, and we have our first author. How wonderful. Senator Cortese.

Item number 12, SB 1300.

Thank you, Madam Chair. I'm pleased to present SB 1300, which is a Bill sponsored by NAMI, the National Alliance on Mental Illness. I want to thank the Committee, staff and stakeholders for working with us so closely on the amendments. I also want to thank the witnesses who are here today, and I'll introduce them in just a minute.

SB 1300 will help communities prepare for the closure of psychiatric units and maternity wards in hospitals. In my district alone, I've experienced the closures of both a maternity ward and a psychiatric unit in less than five years. These units closed despite the hospital as a whole remaining profitable. This problem isn't unique to my county.

It extends across California. As many of you know, according to CalMatters, we've lost 27 maternity wards in the past three years alone. These closures result in maternity care deserts in predominantly low income Latino and other and rural communities.

The negative impacts on families, including decreased access to prenatal and postpartum care, increased travel distance, worsening maternal mortality rates, and increased emergency deliveries. When a psychiatric unit closes, it places additional strain on our behavioral health system.

California is already in a psychiatric bed shortage, which overburdens our emergency rooms, prolongs stays in correctional detention and pushes people into homelessness. This is why it is imperative for local communities to have an understanding of the impact that a psychiatric unit closure will have.

So what SB 1300 would require is that a health facility must provide 120 day public notice of the elimination of its inpatient psychiatric or maternity ward unit. It also requires that health facility to prepare a report that analyzes the impact of a closure on the surrounding community health system.

The report will allow the County Board of Supervisors to assess the closure's impact on the public health system and identify how best to mitigate the loss. I note I use the word allow. There's no mandate on county boards and supervisors to take up the matter, but they may do so upon receipt of the report.

Finally, the Bill increases public transparency by strongly encouraging the county Board of Supervisors to post the report online and, of course, hold a public hearing to provide the community an overview of the impact report. Join us today to testify. We have Danny Offer from Nami California and Caitlin Van Dynes from Healthcare Health Access California. I apologize.

And she'll straighten all that out when she speaks. Thank you very much. And at the appropriate time, I would request an aye vote.

Thank you, Senator. You'll each have two minutes.

National Alliance on Mental Illness, also known as NAMI California. Our wonderful author already outlined the numbers and the effects of these closures. So, you know, I'll just say that we're lucky enough to have seen some recent bed increases, and thanks to Prop one, we'll see more beds come online. But of course, that takes time.

And meanwhile, we're still seeing a lot of these closures, notably in our honorable authors district. So this Bill isn't exactly going to prevent closures. That's a much broader issue than the scope of this Bill. Instead, this extension aims to provide communities with just a little more time to prepare a little bit, but critical time.

Extending the notice period allows for better coordination among local governments, providers, and community organizations. And this will ensure that alternative care arrangements are in place, staff transitions are managed, and the public is informed of how accessing health care might be changing in their neighborhoods.

This preparation can make the difference between a community in chaos and a community that's ready to adapt. As we've been meeting with your offices on this Bill, the question we get asked most is, so why these two? Why are you addressing inpatient psych and maternity wards, this disparate services? Well, if I can quote my mother here.

Madam Chair, permission to quote my mom?

Granted.

Thank you. That's somebody's baby we're talking about. You know, these closures affect somebody's baby, whether it's the joy of having a baby or the anguish of having a loved one who's in a mental health crisis. These experiences are arguably the most significant in our lives.

Happening to the most significant people in our lives. It's challenging enough to plan for these significant moments, even when the facilities are open and operating, let alone when they're slated to close. Thank you, and Katie Van Deynze with Health Access is next.

Thank you Katie Van Deynze with Health Access California, the statewide Healthcare Consumer Advocacy Coalition and we are proud to support SB 1300, which will improve transparency and help communities better prepare to fill the gaps in care if they are able. When a maternity ward or inpatient psychiatric care is closed.

Communities across the country are seeing their local hospitals close labor and delivery care, but California hospitals are closing labor and delivery services at a significantly higher rate. Since 2011, 3% of hospitals in the US have stopped delivering babies, but in California, 14% of hospitals have closed these services during the same period.

Since 2012, 46 California hospitals out of California's more than 400 hospitals have closed or permanently suspended labor and delivery services, and 27 of those closures have taken place in the last three years. Just in 2023, 11 hospitals have announced expected closures of labor and delivery services.

State data shows that the majority of seven closures in Los Angeles were at hospitals making millions of dollars for their investors. And these closures have left large swaths of California without access to obstetric care and have disproportionately impacted low income communities and communities of color. When labor and delivery services are closed.

This leaves longer travel times for expecting parents to reach the care that they need, especially in rural areas but also in urban areas. And these delays lead to impacts on existing infant, maternal and input sorry, excuse me, maternal and infant health disparities.

SB 1300 will increase transparency and give communities more time to help local governments and patients prepare for these closures. For patients to find alternative access to care.

Importantly, the Bill requires that hospitals pay for and develop reports on the impacts of these closures, including the impacts on the health of the community, the potential cost for the county to fill that gap, and demographics of the patients serve at the hospital.

This will help communities prepare, but also give policymakers, advocates, and researchers more information about the closures happening across the state, and this will help inform opportunities to act. I respectfully ask for your aye vote. Thank you.

Thank you. If there are any in support, please come forward. State your name, affiliation and position on the Bill.

Good afternoon. Linda Way with Western Center on Law and Poverty in support.

Thank you. Vanessa Cajina with KP Public Affairs on behalf of the California Academy of Family Physicians and the California Pan Ethnic Health Network, here in support.

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

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

Justin Bowers with CleanEarthforKids.org strongly supports. In addition, the North County Equity, and Justic, facts, ecosustainability peeps and NCCCA also strongly supports. Thank you.

Good afternoon, Madam Chair Committee Members Bryant Miramontes with the American Federation of State County Municipal Employees in strong support.

Madam Chair Member Sara Flocks, California Labor Federation, in support.

Thank you. Are there any primary witnesses in opposition?

Good afternoon, ma'am. Chair, Members, Mari Lopez with the California Nurses Association in support.

Thanks. You'll each have two minutes.

Good afternoon, chair and Committee Members Vanessa Gonzalez with the California Hospital Association here with an opposed, unless amended, position on SB 1300. We really appreciate the author and sponsors working with us over the last few months to address some of our concerns.

However, we do remain concerned with two areas of the bill specifically related to how we believe the county should be involved in the new service closure process that is created by the bill. Also to help align it with current closure processes.

CHA has offered amendments to help with alignment of to help make that alignment, and with that, I will defer the rest of my time to my colleague from CHA, Kirsten Barlow, and also available to help answer any questions.

Good afternoon, Chairman, Members Kirsten Barlow with CHA and wanted to start by saying how genuinely we appreciate and want to honor our relationship both with the author and with NAMI California.

Our hospital Association has partnered with NAMI many, many times to address other mental health crisis issues, and again, appreciate that several of the amendments that we'd been requesting appear to be on track to be made to the bill.

But there are two areas that we want to explain a little bit that we think some reasonable amendments could still keep the additional time and transparency in place.

So, as you know, 1300 require a hospital that is closing in, patient, psych or maternity to be the one to provide a report to the county and to the state about the impact of that closure. We think that's really inconsistent with how other parts of our law, under existing law, expect the hospital to be involved.

So what we're simply asking is for the hospital's report to the state and county to really only include those pieces of information we actually have any knowledge of. It would really be difficult to impossible for an individual hospital to say, if we close this particular service. Here are the new costs our local county will have to incur. There's really no way for us to know that information.

Additionally, we think that given the important role that our local mental health departments play in the delivery of inpatient psychiatric care in particular, they're really best positioned to know, is the closure of this particular unit going to affect the continuum that we have in our community, or do we have some other project underway to make up for the difference of this particular unit closing?

So, as such, again, our suggested amendments would require the health facilities report really only include information that the hospital would have.

We'd also like to have SB 1300 clarify that the purpose of the public hearing that the author indicated earlier would be optional for the county board to have that we simply identify what the purpose of that public hearing is, which is to identify the impacts and actually have a discussion about ways to ameliorate those impacts.

Thank you for the opportunity to share our concerns.

Thank you. Are there any other individuals in opposition who would like to testify? Seeing none, I'll bring it back to the Committee for any comment. Doctor Weber.

Thank you, chair. Well, thank you, Senator Cortese, for bringing this bill forward. I think you and I are working on the same issue around the issue of maternity Ward through labor and delivery units closing. Do have a couple of questions that kind of somewhat mirror what the opposition was saying.

My first question is, why are you proposing that the hospital do the community impact report?

Well, it seems to me, just in terms of my own experience, both as a county supervisor down here in Santa Clara County, which was in our case with this bill, really the genesis of the whole thing, because as I mentioned in my presentation, we have two specific instances that triggered this bill, both by the same hospital system and when we have.

When I have conversations with them as to why there would be a closure, why they were, you know, taking a unit down.

Frankly, they seem to have all kinds of answers as to what not only what the current impact was for them, why they felt that another one of their hospitals could pick up, or somebody else in the community could pick up the slack, if you will, those patients who would no longer be served by that hospital system.

We heard that it's hard for them to get information on impact that the county might perceive. But we tested that just last week because of the regional medical center closure that would happen two months from now.

In August, we contacted the County of Santa Clara ourselves directly and said, what is the fiscal impact of this on the county? That was last week. We received a response to them that the projected potential financial impact is 9 to $7 million annually.

So the county was readily available to, you know, to provide that information to us or to them is the point. They could easily pick up the phone and ask that question to the county, you know, rather than say, we can't get that information. As we all know, the county is a public entity and has a public.

Most counties have a public health department. So that's the idea we're trying to avoid. We're trying to do is really the outcome of the bill that we were trying to achieve.

We can't stop the closures with this bill was to, but to stop the incidents of people being caught off guard, whether they're indigents that need to use the hospital or the maternity system, whether people have loved ones in the psych unit would turn around to the county and say, this closure is happening.

What are you going to do about it? Are you going to have a hearing? Are you going to demand some information from the hospital system in your role as a county so that you can do your job for your constituents and begin further assessing impact of this?

Mostly what we were hearing and experiencing when I was down there at the county with the maternity Ward closure is it's a private entity and we're having a hard time getting any information from them at all.

And we don't really know whether they can afford to extend the life of the unit a little bit longer to allow us to mitigate case of the psych unit. The county is rapidly trying to open up units, as you know.

Of course, as we all know, the state is trying to augment those efforts and open up beds as soon as possible.

So this is the idea here, is to get the county government, which is there on the spot, capable of explaining to the public or opening up public hearings and taking testimonies like we do here today, to have some involvement as soon as possible, as early as possible.

Yeah, thank you for that. I think a couple of things. One, the role of the county Board of Supervisors is voluntary in the bill. It's not mandated. Right. So I think if it were mandated to say, okay, you have to get involved, then I could maybe understand that a little bit more what you were saying.

But it's completely voluntary, so they may or may not get involved. The other thing is, every county is different. Right. And that's one of my concerns with you putting so much of the weight on the county. I recently had, unfortunately, you know, the announcement of a closure of a maternity Ward in San Diego, in Chula Vista area.

The County Board of Supervisors has nothing to do with that at all. That is more of something that we deal with at estate in terms of funding, because we don't have a county hospital. So the county is not going to be absorbing any of those costs. They're not.

All of these patients that would have been delivering at this particular hospital is not now going to go over to the county hospital because we don't have that. Right. So I think that is, you know, also a concern with putting it on the county. Many counties don't have a hospital. Many counties aren't involved in maternity care.

Behavioral health is very different, and so I can see why they may have a role in that. But maternity care overall is different. And the other thing is, hospitals generally have great insight into their own what they do, but not necessarily into what their neighbors do or things like that.

And so when you're talking about a community impact report, I would be a little concerned as a resident to hear, hear from the person that's closing what the impact will be, because they may, and that's no offense to our hospitals, but they may not either have all the information or want to disclose exactly how it's going to be.

And so to have the entity that's actually closing tell you what the impact would be versus someone else who can look and see, I think that would provide a much clearer, unbiased report. The other question that I have is, and, you know, this issue came up with my bill, the notification.

Is there any concern about the fact that you're extending public notification from 90 to 120 days, what that would actually do to the on site workers? Because if there is a risk of closure. Right. And then people hear about that, oh, there may be some instability.

Informing them even earlier may kind of put that risk into reality because people will start to leave. Was there any discussion around that or thought around that?

We haven't. First of all, let me say thank you very much for your excellent work in this area and the process of moving the Bill forward. I've had the opportunity to, to take a look at AB 1895 and try to learn from your approach, knowing that you have plenty of experience in this area.

But thank you for all of that, trying to go back through those issues real quickly. I want to emphasize, we're asking in that time frame for the hospital to use its best efforts to get a report over to the county.

And the county can, as we discuss, opt into holding a hearing or not, or just taking that information under advice in many counties, and I think in many big urban counties, where there's tremendous redlining impact sometimes from these closures. And I'll get into that a little bit more in a second.

I believe there will be tremendous public pressure on the county to hold a hearing, to give people an opportunity to be heard, just give the public an opportunity to be heard as to what the impact is to them in terms of any number of things that I, some of which I addressed in the presentation. Still, the Board of Supervisors may do that or may not.

But if there's a county that doesn't feel like they have socioeconomic concerns, redlining concerns, a hospital system that somehow there's, their safety net is not impacted, which was, of course, we, of course, being a subdivision of the state, as we all know, they're carrying out, if they think the whole thing is agnostic to them.

Then my answer is, that's why it's optional. They don't have to do that. Their General public is understanding and doesn't ask them as local officials to create the convenience and the thoroughness of a county hearing. But let me go back to the redlining. I have lived in all my life.

The east side of San Jose, the poor side of town, full of census tracts of federal communities of concern, majority people of color, majority 40% of our population. In the City of San Jose, overall in the county, our immigrants, 45% of our economic GDP, by the way, is produced by those immigrants, hard-working people.

The maternity closure that took place by this, by the hospital system that we know retail wise as regional, took place right in the middle of the east side of San Jose, so that those women no longer have maternity access in what is, in effect, a populated area that is bigger than most cities in California.

The city overall is about a million people. There's about 600,000 people on this side of town. They're told by that hospital system that they're going to be okay because they can go across the valley to the more affluent side of town and go to the maternity care there. That's. That's what's causing motivation for this bill originally.

That's what created the idea that the Board of Supervisors just might want to take a look at that, especially in a very progressive county like Santa Clara County, to shed some light and to ask some questions about what's really going on here. Is this an economic decision? Is this some kind of institutional, racist decision?

I'm not afraid to say that. Like I said, I live there, or is this just all something we should all feel agnostic about? And I just feel like that hearing, that discussion needs to happen where people who are working 23 jobs and get down to the Board of Supervisors and participate in that discussion.

And I believe in my county, the Board of Supervisors would take that on. I do agree with you 1000%, if there's such a thing as 1000%, that there are counties in this state that would disregard the opportunity to have that hearing or maybe even intentionally avoid having that hearing.

But I think there are plenty of counties where we have plenty of good local officials who will see it as an opportunity for transparency or, in my language, to find out what's really going on. That's really the passion behind the bill.

And it wasn't too long after the maternity Ward closed that we had a psych unit close across town. NAMI and others started to see a trend here. And we have this bill.

I think there needs to be some bill that opens this up and makes sure it's not this very quiet, almost behind the scenes process that it is today. And I sense from looking at your bill you feel the same way. It's maybe just a matter of exactly how to go about it.

But I hope we get there soon so that this doesn't continue.

Thank you, Senator. And we definitely share a passion in this area. And, you know, I've mentioned many times that when we have these closures, they are oftentimes in our most vulnerable communities. They are not in our affluent communities.

And so it is extremely important that we do something about this, but also what we do needs to have significant purpose and actually help out our constituents. So I do thank you. I am concerned about having the hospital do the impact report. I don't think they have the insight.

But I also, to your point, with what happened, even in your city, with them telling the residents, oh, you'll be fine, you can go over there. I would shudder to see what their community impact report would say since they think that community would be fine, they can go and deliver in a more affluent area.

And, you know, I agree. We need to have discussions and we need to inform the community and we need to review the community impact report with the community when it happens. It's just I'm not sure if the hospital should be doing that.

I also don't necessarily think that it should be something at the Board of Supervisor level because at the end of the day, if we're dealing with something, they're closing because of financial reasons, because of medi Cal reimbursement rates, that's not something that the local Board of Supervisors does.

If it has to do with workforce shortages and some contracts, that's oftentimes not necessarily at a local level. So the conversation does need to happen. The question is, who is driving that conversation?

But I definitely appreciate your interest in this area, not only with maternity awards, but also with our psychiatric units and look forward to continuing the conversation so that whatever we're able to do this year is very meaningful and it really moves the needle in the direction where communities will not be impacted, the way in which they have been impacted.

And if we as a state need to be able to step in and intervene, we have the knowledge and the time to do that. So thank you so much.

Thank you.

Vice Chair Waldron.

Thank you. I was going to ask the similar questions, but I won't repeat what my colleague so eloquently said, I do too, also have a concern about having the hospital be responsible for all of the impact report.

I was kind of listing some of the entities that would be involved or could be, not only the county at whatever level, but whatever the behavioral health providers, what they would say, a local economic development corporation. We have a very robust one, San Diego, as well as Riverside counties, EDC, as well as the hospital system.

So I just wanted to get that in there. But I do appreciate the early notice because I remember being eight and a half months pregnant and getting the notification from my.

It was a health plan that everything changed, and now I had, my obstetrician was no longer going to be there and I wasn't going to be treated at the same facility I thought I was. I'd have to go 70 miles away. So that was very traumatizing. So I do appreciate that.

I did want to just broach the part about the State Department of Public Health, prioritizing licensing of additional beds to replace the number of lost beds and how that would be done. Like how you see that happening, that we could actually move the State Department to do something like that, because I think it's important.

Is that a question for me?

Well, I see it in the bill, in the bill language, and it's in the legislative digest, actually.

Right. I mean, it's language intended to encourage. I think, you know, we're all aware of what the obstacles are right now, including just resources and what the Administration has been doing leading to try to get us in a position to meet the needs in terms of beds, let alone respond to backfill right away.

But of course, in the day to day community, our constituents want to ask that question almost first and foremost, what is the state going to do to replace these beds? What's anyone going to do to replace these beds? Which I think in some counties is an appropriate question as well for the Board of Supervisors.

The answer may be nothing right now, but the idea is to, to call the question and see if there are answers available. I'm happy to defer to the witnesses, too, if you want to get a further response from them.

Yeah, I mean, I think having them in the conversation as the whole process is going forward is helpful to get it on their radar, and we hope that they would look at it.

Thank you, Senator Cortese, for bringing this bill forward. I think I really appreciated you focusing in on what drove you in the first place to bring forward this bill. I think very similar to Doctor Weber, Doctor Weber's bill grew very concerned with the impact that a single hospital closure can have.

And I think we need to acknowledge that it does impact the entire community and the entire county and being able to do it.

And I really appreciated in your presentation that you talked about kind of the silence of that happening, or the need to sunlight, the fact that we need to have that be shared out in the public for that to happen. At the end of the day, hospitals are places of care. They're also businesses.

In your legislation, as it's currently worded, you are focused on the community impact analysis being one that includes a good faith estimate of the impact of the closure on the county. So that's the burden is kind of a good faith estimate of what that impact is.

Hospitals, and from either set of witnesses, hospitals provide, have a sense of how many individuals are available. They know their market, so to speak, and they know how much they spend on that market.

And my read of this legislation is essentially one, to be able to have that hospital share the sensibility around the understanding of that market and the impact of their removal of service on that particular market.

And the second piece, which I think is very critical, is to have there be some cognizance around it being a regional or a county level, having a regional or county level impact on that.

Third is that you're sunlighting these conversations that have grave impacts that cause, as assemblymember Waldron said before, can cause a birthing person to have and a woman to have to travel up to two to 3 hours to be able to get the care that they deserve to be able to deliver their babies. That's happening right now.

It's a problem that needs to be addressed very broadly.

And just to offer as a counterpoint, I do believe that the Board of Supervisors, the county level look is the appropriate space, public space, for a hospital to have to come forward and essentially provide their good faith estimate of the impact of their closure of particular services on the overall population that they are able to serve within their particular market.

So with that, I would offer you an opportunity to close and perhaps address that particular issue. But I do believe you are on the right track.

And it's concerning to me now that we have two or three bills that are focused on hospital closures, because we're really needing to address the overall concern, which is that our hospitals are closing at a rate that is untenable for California's public.

Thank you, Madam Chair. Appreciate your comments and a couple things. As part of the close, we did not accept all of CHA's proposed amendments. We accepted three out of four and if you need me to clarify what those are, I'd be happy to do that.

What we did not accept is what Doctor Weber was focused on was who should do the impact report. They would like the state to do that. Which raises a couple of issues currently.

One is certainly a significant appropriations issue, which we don't have to worry about with an opt in at the county level, to be very candid about that.

And the other we're concerned about is at least our county sources that from the county where the bills primarily being sponsored, meet, you know, reiterate that they could put something on the agenda any given Tuesday, and in this case they would, or they will, in order to try to dig into some of these issues and shed some sunlight.

I'm not clear. We couldn't get clear in our case, and maybe some of the other authors, like authors like Doctor Weber, could. I should talk to more to find out. But we could not get clear on the turnaround time happening at the state level timely enough to get community information back before the closure actually occurred.

We believe at the county level, for those counties that opt in, that they would do that. We're open to obviously continuing to work and refine the Bill or align it better with other practices or other pending legislation. Again, I try to focus, and focus my own staff on outcomes.

What is the outcome we're trying to get to, and the outcome? The outcomes we're trying to get to would be primarily sunlight, transparency in the community, an opportunity for the community to be heard, and an opportunity for local officials to begin the process as early as possible to try to mitigate any actual impact that's out there.

It could be as simple as creating adjusted EMT or first responder services that are bridging the gap geographically that you alluded to. We don't have a three and a half hour delay, necessarily, but I know that the chair is a Bay Area caucus person.

So you, you know, and people who have visited my lovely city know that at many hours of the day, many hours of the day, much like the beautiful City of Los Angeles trying to make it 12 to 15 miles across the valley, it can easily be an hour and a half, an hour and a half delay, if you will, or an hour and a half commute, even in the best of circumstances.

No accidents, no other issues, just congestion itself.

And I have not birthed, but I been the father of four children and been involved in getting back and forth to labor and delivery services, for example, trying to deal with that and do it in a way that's going to provide a healthy outcome for the patients themselves and incur delays.

That would be an hour and a half more than if the maternity unit stayed open in the first place. It is, in and of itself a serious and significant impact, I think. And then when it, in effect, doubles down the impact from, frankly, a racial and ethnic standpoint, to me it looks like modern day redlining.

That's what it looks. A corporate entity saying, we can't do this anymore because it's not a money making unit for us anymore. If we consolidate it with another hospital that's an hour and a half away in traffic, it will be financially and fiscally viable for us.

At some point, we have to have a discussion about the social and corporate responsibility here and what it means to the quality of life for people living in these districts, in these service areas, if you will. I don't think, from what I heard today there's any disagreement about that.

I would ask you to give us an opportunity to, you know, as close as we are to getting to the end of this year's voting session, but as hard as we've been working, and I think the opposition acknowledged that, to give us the opportunity to keep working, to try to get a Bill to the Governor that, you know, satisfies all concerns or as many concerns as possible.

And with that, I would respectfully ask for your aye vote thank you.

And we will consider that when we have a quorum. Thank you for your presentation, Senator.

Thank you.

We are waiting for authors.

I guess we're done. I think it's probably so. Lehman is on her way right now. And then Durazzo is in another Committee presenting, but they'll be here as soon as possible. Looks like Becker. We still can't get an ETA for them. And then for Portantino?

They're still in meeting over at the swing space, but looks like Leland is going to be our best bet. On their way now. So it.

Still needing to be heard SB 402 Wahab, SB 909 Umberg, SB 957 Wiener, SB 963 Ashby, another Wahab Bill SB 980, SB 1120 Becker, SB 1147 Portantino, SB 1180 Ashby, SB 1266 Limón, SB 1319 Wahab, SB 1333 Eggman, SB 1382 Glazer, SB 1397 Eggman, SB 1447 Durazo, and SB 26 Umberg. We have a Committee waiting for an opportunity to hear your bills.

Senator Limón, item 11, SB 1266. You can proceed whenever you're ready. Thank you, Senator.

All right, thank you, Chair and Members. SB 1266 seeks to prohibit a manufacturer from selling children, feeding, sucking or teething products that contain any form of bisphenols at a detectable level of 0.1 parts per million.

Bisphenols is commonly referenced as BPA and BPS is a chemical compound that is used on a variety of industrial and consumer products ranging from automobile parts to food containers. BPA is considered an endocrine disruptor, which means it can interfere with the hormone system in the body and can have adverse health effects in children and adults.

Since 2012, the US Food and Drug Administration has banned BPA from baby bottles and sippy cups. However, not all the products. SB 1266 strengthens the commitment to protect children from harmful chemicals and authorizes the Department of Toxic Substances Control to establish tandras, prioritizing the health and wellness of our children.

With me today in support of the bill, I have Nancy Buermeyer on behalf of the Breast Cancer Prevention Partners.

You'll have two minutes. Thank you.

Hello. Okay. Good afternoon, chair and Members. Nancy Buermeyer on behalf of Breast Cancer Prevention Partners, thank you for the opportunity to testify and thank you, Senator Limón, for your leadership on SB 1266.

This bill expands the ban on BPA and baby bottles and sippy cups to all feeding, teething and sucking products for children 12 years and under and bans the entire class of bisphenols. BCPP is a science based organization working to prevent breast cancer by reducing our exposure to chemicals linked to the disease.

Bisphenol A, or BPA, is a chemical we are deeply concerned about given its ability to disrupt our hormones and its link to breast cancer and numerous other health harms. BCPP worked with our allies to remove BPA from baby bottles and sippy cups many years ago, and today you will see BPA free stickers on numerous products.

Unfortunately, all too often, BPA was replaced with an AlphAbeT soup of bisphenol substitutes, BPS, BPF, BPAF and so on, banning the entire chemical class addresses this issue of regardable substitution. While these other bisphenol chemicals are often less well studied the more we learn, the better we understand that the entire class has implications for our health.

Including increased risk of asthma and hyperactivity in children and cardiovascular disease, fertility problems, obesity, diabetes, and an increased risk of breast cancer, breast and other cancers in adults.

According to the CDC, over 90% of us have BPA and BPS in our bodies and over 65% of us have BPF. They disrupt the very sensitive balance of our hormones and have profoundly negative effects at very low levels.

Early life exposures are particularly concerning because this developmental period is when these chemicals have their biggest and longest lasting impact and can increase our risk of disease, often decades later. This early life impact is why SB 1266, which addresses exposures to children, is so important. Thank you again, Senator, and we urge your aye vote.

Thank you. Are there any witnesses in opposition? Oh, sorry. Are there any additional witnesses in support? Please come forward. State your name, position on the bill, and affiliation.

Good afternoon, Chair Banta and Committee. My name is Leah Jones, on behalf of A Voice for Choice Advocacy in strong support of SB 1266. Thank you.

Hey, folks, Crystal Reynaez with Californians Against Waste in support of this bill, as well as Clean Water Action in support. Thank you.

Are there any primary witnesses in opposition? Any other witnesses in opposition? Seeing none. I'll bring it back to the Committee for comment or question.

Thank you, Senator, for bringing this forward. It's so hard for me now to see children with a binky, or whatever they call it in their mouth now, because I've known this for a while or felt like there something behind this.

Thank you for bringing it forward, and let's make sure there's awareness for our mommies and daddies of the concerns that come with this, with those little products for those babies. Thanks. Give them a blankie or something new. Right? Some other comforting thing.

I want to thank the Senator for bringing forward this bill.

It certainly, I think within the timeframe that my now 15 year old and upper, we had the issue of BPA's in bottles and sippy cups and the like, and now the expansion of that to other analogs is absolutely critical for all those who want to be able to ensure that their babies are not having to ingest toxins while they are being soothed or fed or having basic needs addressed.

So with that, would you like to close?

I respectfully ask for an aye vote.

And when we have quorum, we will consider that. Thank you so much. Move on to item number 17, SB 1447 Durazo. Thank you, Senator. Whenever you're ready.

Thank you, Madam Chair and Members, I'm here to present SB 1447, which will provide an extension for the Children's Hospital of Los Angeles to comply with additional seismic safety retrofit upgrades.

Children's Hospital of Los Angeles is a premier pediatric hospital providing care for some of the most difficult pediatric cases in the region and the only children's hospital in the region.

CHLA and the care it provides for children has become more important to the region as other hospitals and healthcare facilities have begun to close or downsize pediatric care units. The hospital often receives referrals from other hospitals and takes those cases without regard to the ability of the family to pay. Children's Hospital does not turn anyone away.

In fact, 70% of the children are insured by Medi-Cal, meaning very low-income families, yet they get the highest quality medical attention. CHLA takes its responsibility to have a safe hospital for its staff, nurses, doctors, and patients very seriously.

CHLA has already met the primary earthquake retrofit structural standards required by law to assure that its structures can survive a major earthquake and be functional.

The next set of retrofit standards applicable to Children's Hospital are aimed at various infrastructure improvements to make sure that the hospital and its campus have adequate water, sewer, power generation, and other infrastructure so they can independently support operation of the hospital for a minimum of 72 hours after a major earthquake. These standards are mandated by 2030.

Meeting these standards is estimated to cost approximately $230 million. While CHLA has been working to both plan and achieve compliance with these updates, CHLA has a primary role to provide acute health care for the region's children, regardless of the family's ability to pay.

As a result, complying with the infrastructure standards by 2030 would place a severe hardship on the hospital.

Providing a three-year extension with the ability to request up to five more years if specified criteria is approved by the Department will allow for both the financing plan and the construction to be implemented, and at the same time allow CHLA to continue providing the critical care for pediatric patients from throughout the region.

I look forward to continuing conversations with all stakeholders and I will work diligently to find potential solutions to address concerns about extensions and ensuring that Children's Hospital can meet the seismic requirements in order to continue providing critical care and ensure the safety of its patients and employees.

With me today, I have Paul Viviano, President and Chief Executive Officer of Children's Hospital Los Angeles, and Joe Lang, who can help answer any technical questions. Thank you, Madam Chair.

Thank you. You'll each have two minutes.

There we go. Joe Lang, representing Children's Hospital Los Angeles. The center's correct. We have met structural building standards from 2020 that the hospital is required to meet, had a plan to comply with the 2030 standards, which are infrastructure oriented. Unfortunately, in the process of beginning to implement that plan, CHLA was hit with two primary problems.

One, a funding reduction of approximately $80 million a year as a function of changing the formula by which the children's services program reimbursed for those critical care severe ill children. That was about $80 million a year. That was instituted back in 2018.

At the same time that that was happening, upwards now of almost 30 hospitals in the region have begun to close their pediatric wards. As a result, Children's Hospital of LA became more of a safety net for the children in the region at the same time they were experiencing that funding downturn.

As a result, Mister Viviano here, who I'm going to turn it over to, had to make difficult decisions to maintain care as the safety net for those complicated and severe cases in the LA region, while also planning for this compliance. Mister Viviano, I'll turn the ball to you.

Thank you very much, Chair Bonta, Members of the Committee, it's a privilege to be here this afternoon. So, a little bit about Children's Hospital of Los Angeles. We're the largest children's hospital in the State of California and treat the largest number of Medi-Cal beneficiaries in the State of California as well.

Our hallmark is caring for the most severely ill children in the state. We have focused our growth on liver transplants, neonatal heart surgery, bone marrow transplants, complex epilepsy treatments, craniofacial disorders, brain tumors, Spina Bifida, congenital heart conditions, and a variety of other very significant transplant opportunities.

We care for more than 50% of the most severely ill children in LA County, more than 25% of the severely ill children in Southern California, and more than 20% of the severely ill children in the State of California.

You've heard that 76% of our patients are Medi-Cal beneficiaries, and we stand proud with the legacy of Children's Hospital Los Angeles, that we turn no patient away, regardless of their financial circumstances. So, given the time crunch, I want to focus on the couple things that Joe highlighted.

We spent $1 billion 10 years ago to build a new tower, and we accommodated all the seismic requirements. We had built a tower big enough to care for all the children that we thought we would need to take care of going forward.

Two things have happened since then more than 30 hospitals in LA County have closed their pediatric units, and we were faced with an agonizing decision. Do we reopen those units that were closed because of the seismic conditions or reopen them and care for those children? We obviously chose the latter to reopen those beds.

We care for those children. And at the same time, our reimbursement declined, so we need more time. We want to be in compliance with the seismic requirements. We intend to be in compliance with them. We just can't do it by the year 2030.

We want to continue to take care of all those precious children in LA County and far beyond that deserve the best care. Thank you very much for your consideration.

Thank you. Are there any other witnesses in support? Please come forward. State your name, position, and affiliation.

Mira Morton, on behalf of the California Children's Hospital Association in support.

Aare there any primary witnesses in opposition? You'll each have two minutes.

Thank you, Madam Chair, Members of the Committee, Megan Subers, on behalf of the California Professional Firefighters and with the most respect in the world for the author and acknowledging all of the really important and amazing things that this hospital does. CPF remains opposed unless amended to this bill.

And our amendment is a request that the extension be limited to two years. For context on our organizational position on seismic extensions. Historically, we have opposed blanket extensions. In some rare and unique cases. CPF has remained neutral on extensions of two years or less. So, our position on this bill remains consistent, and that's for a few reasons.

First and foremost, safety. If a building is deemed, a hospital is deemed non-compliant with the 2030 standard, the hospital must be evacuated. That means that my members are sent to hospitals to evacuate patients.

And a few things come to mind for me, the safety of my members, but also the patients, and in this case, children and the other workers and providers that are in that hospital. We are going to have many calls for service during a natural disaster like an earthquake.

And so, while we're trying to evacuate a hospital with acute patients and responding to other calls for service in the community, how many ambulances are available? Where are we supposed to take these patients?

Where is the nearest children's hospital that can accommodate the needs of these patients in this particular hospital are all things that we have to consider. We also have concerns about what this means to provide an extension. Here we are in 2024. There's still a little over five years to meet the 2030 standard.

If we give any hospital an extension past the 2030 deadline, what is the incentive to try to meet that 2030 deadline today when they still have five years? According to the State Treasurer's Office, Prop. 4 passed in 2018, which provided $1.5 billion in bonds to children's hospitals in California.

You can look up and see every children's hospital that has availed themselves to the money available to that hospital. What their expenditures have been, how much they have available, would encourage folks to go take a look at that. But at this time, for those reasons, we remain opposed unless amended. Thank you.

Thank you.

Madam Chair and Members, Sarah Flocks, California Labor Federation, and almost all of our unions have a small unit that works in healthcare and hospitals, everything from healthcare workers to janitors to food service.

And so, we are here in respectful opposition of this bill, much respect for the author, and also respect and recognition of the critical role that Children's Hospital plays in Los Angeles. That is one of the reasons we are here, is because with the closures of the pediatric units, there is nowhere to go.

There are not appropriate hospitals to go if there is a seismic event and children have to be evacuated. It is critical. It is critical that this hospital remain operational and that is the goal of 2030.

And we have seen over the decades that, as my colleague said, when you give time, extra time to hospitals, that gives room to prioritize other things. Patient care, MRI machines. We've seen this over and over and over again. That's why we are running up against the 2030 deadline, and hospitals are not coming into compliance to be functional.

And we see, recognize that the voters have supported this hospital through bond measures. We would urge that there be that the hospital, because it's also nonstructural work that needs to be done, find a way in the next six years to come into compliance. We just think this extension is way too long. Thank you.

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

Good afternoon. Beth Malinowski with SCO California. Aligned with my labor colleagues in respectful opposition unless amended.

Good afternoon. Mari Lopez with the California Nurses Association. We appreciate the dialogue that we've had with the Senator, but we, too, remain in opposition, especially in consideration that this is a children's hospital.

Thank you. Seeing no other opposition, I'll bring it back to the Committee for questions or comments. Mister Jones-Sawyer, then Schiavo, then Rodriguez.

And thank you. And seeing that the Children's Hospital Los Angeles is in my Assembly District, it's actually in walking distance of my home, and I've been visited several times. I want to start with commending Children's Hospital for at least meeting the seismic retrofit portion of it. It's a daunting staff, a task, and it takes a lot.

I know Senator Durazo and I remember the Northridge Earthquake where 16 people were killed and the number of people that were found under slabs of concrete during that time. And to have children found under slabs of concrete would have been very, very upsetting to the psyche of the region to maybe into California.

And so, I commend you for getting that part done. And my question, because I'm not really sure, when you say, I need to do the sewer, in my mind, does that mean you need to get a plunger, you need to get a snake? Are we building new sewer lines that need to be in?

Why does it take so long when you say, what are those other things? Because that is another problem.

If you can't stay open or you can't provide medical care during the next earthquake, and we will have another earthquake, then it's obviously not as bad as if it collapsed, but it could be a catastrophic, a different level of problems.

But I think if we had a little more clarity on what it will take to do this, this may help not only us, but also others who are asking for shorter time for you to complete it, because we're not understanding the full breadth of what it would take to do that.

And obviously, I used to be in director of real estate. If you need to sit down and talk about how we can cut some corners and put our foot in some contractors' butts, we can talk about that, too.

So, your assessment is correct. The structural rating of the four buildings in question at Children's Hospital Los Angeles are SPC 2 categories, so they're not at risk of collapsing. So, the structural infrastructure has been taken care of, as you've identified. So, our newest tower, 320 beds, completely compliant.

The four older buildings that house roughly 80 beds are structurally compliant. But there's infrastructure needs. That's a supply of water for 72 hours past a major earthquake.

What would that entail you needing to do? I guess is what I'm, or is that something we need to do offline to talk about?

It's a substantial investment for additional water supply to be housed on the hospital campus. So, there's a substantial construction project for that water supply to be created. And the sewer lines need to be expanded per the requirements of the state for the non-structural requirements, the infrastructure requirements, as was indicated, that's $230 million.

There's electrical requirements also that need to be addressed. $230 million to make those investments, to make all those things possible, and to keep those beds open during that process.

So, the hope is that by passage of this bill, we would then be able to take a portion of our capital budget every year, allocate it to this process, get the state to approve the plans, and then implement it over that period of time. Obviously, if we can do it sooner, we would do so.

We believe this is what it's going to be required in order to address the timeline. And please note, this is a three-year extension. We would have to then demonstrate to HCAI that five years would be necessary as well to extend if the projects are underway and can be completed in that timeline.

So, thank you for the great question. Hopefully, I've addressed your concern.

Look, I will vote on it today and hold it when we get to the Floor so we can have a discussion about is this a new power generator, that emergency generator that you're talking about? A super emergent. I don't want to, we get into the weeds now, but I want to get into weeds later.

Come on over, we'll take you on a tour. We'll show you what it would require. All right. The generator's capacity, it's actually the power flow into the buildings that needs to be updated again. They're fully functional today. Thank you. Thank you.

Schiavo.

So, just a similar vein of questions with my colleague, Mister Jones-Sawyer. And so, it sounds like the issue is more financial. It's not so much about the construction being able to happen in the timeframe, is that right?

That's part of it. And so again, to reiterate, we spent $1 billion coming into seismic compliance with all, with our new tower. We reopened those beds and so we've been forced to make that decision. Do we reopen the beds knowing that we can't make the 2030 deadline?

During the past five years, Medi-Cal reimbursement to Children's Hospital Los Angeles has declined by over 25%. So, the average per-case discharge reimbursement to us has gone from $44,000 to $31,000. So. that's impacted our balance sheet and our ability to afford this in that timeline.

So, it's both a matter of planning, keeping the beds open as well as affording it. So, you are correct.

Okay. And I, and I recognize, you know, the recent financial hardship. I am willing to do a courtesy vote today as well but have concerns.

And so, I guess setting the financial piece of this aside because, you know, my general concern comes from this is something that's been, there's been requirements around this for decades now at this point. And it's been a very, very long time.

And it seems like every few years since, I think it's 1994 that all of this started, and then there's been extensions since, I think, 2007 or 2008, it's been extension after extension after extension after extension. So how can you demonstrate, or how will you demonstrate?

What can you show us now that's already in process to kind of trust that this is going to move forward in earnest? Right? And also, what will you be demonstrating to, you know, if this is passed, what will you be showing to make sure that this is actually moving forward and you're not?

I mean, if you can get it, we have five and a half years. Right? And if you get another two, that's seven and a half years, but then another five, that's 12 years. You know, that seems like a long time.

So, again, the first demonstration is we spent $1 billion coming into compliance.

Right. Which is a lot of money.

I agree with you.

Which is a lot of money.

And we issued debt. We raised some money and did a magnificent new project. And all those old beds were closed. And so, the environment, 30 hospitals, closed their pediatric units in LA County over the last six years.

Last week, St. Mary's in Long Beach announced they're closing their pediatric and their PICU. In a city with more than 450,000 residents. Unthinkable. Where are those children going to go? They're going to come to Children's Hospital Los Angeles. So again, it's this agonizing choice that we have. We want to keep down 12% of all the pediatric beds in LA County.

The biggest county in the state are in those older towers. There's no place for these children to go, and so we want to keep them open. We'll go as fast as we can. We've asked for the three-year extension plus five years if we're making progress, and HCAI approves it.

So, those, there are milestones in the bill that Senator Durazo has introduced that would require us to make those milestones in order to get the extensions. But you're correct, we can't afford it today because of the impact on our balance sheet COVID, as well as the impact of reduced reimbursement.

So, $230 million in an organization with a pretty stretched balance sheet is a very substantial investment. So, we believe it's going to take that amount of time to create those resources. Like many hospitals in this state, we have no debt capacity. We can't borrow any more resources today. That's helped explain the context of it.

And we'd be happy to go into more detail with you and your staff, if you'd like.

Yeah. Thank you. And I'm deeply grateful, as someone who represents LA County as well, deeply grateful for the work you do to take care of our kids. I also represent Northridge, where the Northridge Earthquake happened. And so, you know, we got to balance things. And so, so I hear what you're saying about not having the money now.

Are you able to take steps forward as money comes in, or are you going to have to wait seven years before you can start spending?

We're going to reserve some of the money each and every year in order to afford it.

And start moving. But aside from saving the money, getting the money to do it, the work part of it, when does that start?

We anticipate starting in about three years, actually, starting with these projects.

Okay. Okay. Thank you.

Thank you.

Mister Rodriguez.

There you go. Yes. First of all, I just wanted to thank the folks there from Children's Hospital. I've been there many times, taken a lot of patients there, traumatic patients, and also been part of the cardiac team where we're transporting patients from, like Loma Linda and others. So, fabulous work you guys do. Commend you for everything that happens there.

Thank you.

But I do have concerns, obviously, with the continued extensions. Obviously, seems like every year, matter of fact, I think last week we just had an extension on another hospital. So, my think is, what do we start doing to kind of have some type of insurance backup plan?

I've talked to many times before regarding mobile field hospitals that we should look at having some mobile field hospitals or look at funding for one or two.

It'd be ideally if we have one in Southern California, Northern California, because once again, like some of my colleagues talked about that Northridge quake over 20 years ago, we haven't been tested, you know, as far as things have been done since then till now.

And obviously, I was the first responder there in Northridge, and I've seen some of the devastation that occurred, especially the apartment complexes.

So, I just want to see, as we continue to move forward in granting these extensions, because obviously, the reasons you have that we need to really take a look at what can be an insurance plan to support in case something were to happen within a year. Right?

Some type of a backup plan, because as our firefighters and our workers talked about, who's going to be moving those patients when we're going to have some chaos in some cases, depending where that earthquake happens, whether it's in the San Andreas fault down or up here in the bay or at the Hayward fault, right?

So, let's just move cautiously on that, and maybe we start looking at other alternatives to support hospitals if they do go down, which they probably will, depending on where the earthquake is, that we have the resources there to take care of the folks that are going to be needing the help.

So, just want to keep that in mind. And once again, these are some, some of these types of bills are really difficult for me to support because I see both sides. But then ultimately, we're here to protect the people. Right? To the best of our ability.

And if we continue to delay these extensions, and we don't know when that story's going to happen. Right? Hopefully, it doesn't happen in a long time, but there's no, nobody can tell us it may happen next week or tonight. Right? But let's just reassure that we're doing our best to keep those in mind.

Again, these are tough choices, and we appreciate it. And one of the worst alternatives here is to close 12% of all the pediatric beds in the largest county in the state. And so that's the tradeoff, and that's what we're trying to avoid, is to be able to do both these things in a timely way.

Thank you.

Majority leader.

Thank you very much. I've been here for eight years, and this comes up almost every year. And it's so frustrating because obviously it's here about the safety of our community and our patients. You, I have fixed one of the towers. One of the towers, correct?

During that time that you're doing that, did you already do the planning for the other four facilities for the seismic?

Yes. Correct. So again, the structural work's already been done. This is the infrastructure work. We have made those plans. Correct.

Okay. So, I just want to make sure that that was clear, and I must have missed it, but I was just concerned is, are we going to start continuing to plan? And I'm hoping if you spent $1 billion, you've kind of got all that taken care of again.

It was taken care of in the new tower. The old towers were closed. We've reopened them as the demand has increased with other hospitals closing their pediatric units.

So, my heart goes out to you because I know this is a really tough thing. I worry about my workers because I've taken tours of numerous hospitals in Northern California. They're much smaller, they're much more rural. And I'm hoping we're not opening up a can of worms, opening this up for a longer period of time.

So, I just want to give you that. There are two other bills, am I correct that are coming through with seismic concerns as well? Senator, I would imagine you're going to have conversations with those other authors on seismic or because I think we should be doing one bill, not three bills quite frankly. Maybe that doesn't work. But.

Frankly, I'm focused on Children's Hospital. I'm not opposed. And I think conversations like that, I've had conversations, some conversations already, but I'm focused on Children's Hospital. And it's not to say that other hospitals aren't important. Every single one, small, big, rural, urban, they're all, they're all really important.

This particular hospital, of course, dealing with our kids and our babies and where the growth of children coming to the hospital, it's not like they've been able to meet the needs and the, you know what, the services for their current needs. They really are now having to expand their services, expand their needs.

And I think that's the part, that part of what caused me and compelled me to work on this particular hospital.

Well, I appreciate what you've done for this bill. I understand your concern for your district. But you know me, I'm always going to bring up my rural communities. I will always do that. But that's for a discussion later. But I'm just going to encourage you to continue to work on the bill.

I'd like for you to spend some time with the other authors that are doing seismic bills because safety is number one. And I think we need to keep an eye our entire state. So, I want to commend you.

I will support you today and I hope to see a bill that might be a little bit inclusive of some of the other districts. Thank you.

Thank you. One other just follow-up conversation that is the concern of workers as you've rightly identified. These buildings are not in danger of collapsing. They are ranked SPC 2. HCAI has said they're not. This is not a life safety issue for the workers or anybody in the building. Just to reiterate that.

I've lived through an earthquake.

Thank you. Seeing no other comments from Committee Members, I want to thank the author for bringing this forward.

I know that you are a champion of workers and didn't take this bill on lightly as you were considering balancing the ability to keep our community and our workers safe while we also ensure that we have an opportunity to have this hospital open.

That being said, there are two pieces of legislation, AB 869 by Doctor Wood and SB 1432 by Caballero, that are going through the legislative process right now that take a much more holistic approach to considering these seismic compliance issues and the deadlines associated with that. We have had a couple of other one-offs.

I had one last year around Alameda Hospital related to just kind of making exceptions. I know that that's in the Governor's veto message. He desired a more comprehensive solution. I know that you will continue to work on this bill should those other two bills come into review and are accepted by both the Senate and Assembly.

And with that, would you like to close?

Thank you very much. And I agree with what everyone has said as far as our concerns, our care, our care for everyone, including the employees who make the hospitals work. And it is difficult, but we are having good conversations.

We haven't reached agreement with those who oppose this particular bill, but we know we care about the same thing, so we just have to keep at it. And I hope for today and all the way through the process, you continue to support this bill. Thank you.

Thank you. We haven't established quorum yet, but when we do, we will review the item. We'll move on now to our next bill, which is item number two, SB 402, Wahab.

Please go ahead whenever you're ready.

Thank you, Chair and Colleagues and members of the public. First, I would like to state that I accept the committee amendments. SB 402, appropriate response to mental health crises, is about ensuring people in a crisis are met with compassionate response of a trained, licensed mental health professional. Under existing law, counties have the latitude to designate whomever they want, which also means they have the ability to restrict who is designated however they want.

By naming specified licensed mental health professionals, SB 402 ensures any restrictions on who may be considered for county designation do not unnecessarily limit licensed mental health professionals who are not employed or contracted by the county. The decision-making phase of initiating a 5150 does not always include the active involvement of mental health experts, which leads to poor outcomes for the individuals in crisis in their communities, more specifically communities of color or those that do not speak English.

Prop 63 was passed by California voters and resulted in community-based organizations providing prevention and early intervention support, but licensed mental health professionals within these organizations are limited in their ability to fully support their clients in crisis, even though they may be licensed and credentialed by the state with the hours that is required to receive this credential. We are talking about professionals who have established trust with their clients and communities.

Within my own Afghan community, I have seen highly qualified mental health professionals with the skills and cultural competency to support their clients through crisis having to rely on police because they themselves are not empowered to support their client through the whole process.

The unnecessary police involvement not only escalates matters, turning a nonviolent situation sometimes into a violent one or one that escalates unnecessarily, it also creates trauma for the client as well as the families involved and those that are bystanders. Our current framework definitely needs significant help, and we put a lot of pressure on law enforcement to initiate a 5150, specifically resulting in potential delays and much more.

SB 402 seeks to address these issues by ensuring licensed mental health professionals, specifically LMFTs, licensed clinical social workers, LPCCs are able to pursue the county designation process regardless of their employment or contract status with their county. This will encourage counties to think more expansively about how to approach these processes and have the frontline workers at the table when they are engaging with those that are in crisis.

We know we can improve our response to nonviolent crises when LMHPs initiate a 5150 and there's no indication of violence or a weapon, there is no police involvement. We see this in the Community Assessment and Transportation Team, otherwise known as the CATT team, and the Hayward HEART Team, which pairs EMTs with a licensed clinician, significantly reducing involvement of law enforcement.

We also see this in Alameda County program that has designated LMHPs within five community-based organizations not contracted by the county, and has been an overall decline in 5150s as a result. Provisions already exist that ensure police are involved when there is violence.

Existing law also makes provisions for designated professionals, persons, and mobile crisis teams to transport individuals where there is no violence. SB 402 aims to support these frontline licensed mental health professionals and their clients to ensure response to mental health crises are more appropriate, humane, and compassionate.

We've had a lot of great conversation about this bill, and I want to state that I understand the gravity of what it means to take away someone's rights with a 5150. I have been involved with a number of community-based organizations over the years and have seen far too many people go without the help that they need.

Their families struggle, let alone they themselves. This is not something I take lightly, and I know that so many marginalized people need the help that they truly want to get. LMHPs also understand the gravity of a hold, and they do not take it lightly. SB 402 simply ensures that counties consider licensed mental health professionals, regardless of their contract, employment status, to work with the county and so forth. I would like to introduce my first witness, Justin Phillips, a licensed marriage and family therapist, MAC, Executive Director of Options Recovery Services.

Thank you. You'll have two minutes.

Thank you. Thank you, Madam Chair and the Committee for allowing me to be here today. My name is Justin Phillips. As the Senator mentioned, I am a licensed marriage and family therapist, a master addiction counselor, and the CEO of Options Recovery Services. We are a statewide addiction and mental health treatment organization.

I'm also here representing NAADAC, the National Association of Addiction Professionals. I serve on the board for that organization and that addresses addiction and mental health issues throughout the nation. I've been working in the mental health field for over 20 years in a variety of capacities. Some of this experience is in locked psychiatric facilities.

I've worked in detox facilities. I've worked on the streets. I've worked in mobile encampments. I've worked with the homeless. I've worked in a variety of communities of underserved people. And I can tell you that what's happening is not what appears to meet the eye.

In most cases, the most successful initiation of a 5150 is done by a licensed professional. We see this in Alameda County and we support it. I, as a licensed mental health professional, am also a person who is a recipient of benefits for having a disability. I was in the military and received traumatic experiences there that allowed me to be a consumer. Ultimately, it's important to mention that we collectively have a duty to support the most underserved and underprivileged of our communities.

It's the people that are helping these people in the communities that need to have more authority to be able to make decisions. It can be traumatic, extremely traumatic, and even more traumatic to individuals who are improperly 5150ed and not initiated according to therapeutic values. So compassion is at the center of this, and I want to thank you all for this opportunity to be here today. Thank you.

Thank you. Are there any other witnesses in support? Please come forward. Name, organization. Seeing none, do we have any witness for testimony in opposition?

Hello? Okay. Hello, Vice Chair and Members. My name is Rachel Bhagwat, and I'm a legislative advocate at ACLU California Action. I've also worked in the mental health field for a number of years before doing this work, and a consumer of mental health services as well. The ACLU deeply regrets that we have to oppose SB 402.

We're regretful because we agree with the highest level premise of this bill, the idea that we need health-focused, not law enforcement-focused responses to mental health crises. However, the approach to this bill is not right. SB 402 will actually increase calls to police for mental health crises and will lead to more people being placed in involuntary commitments who could have been served by voluntary crisis services.

If law enforcement is inappropriately placing 5150 holds, then we need to limit the instances where they respond and double down on our state's new mobile crisis programs, alternative transportation pilots, and voluntary crisis care destinations. But SB 402 doesn't coordinate with any of that.

Instead, it would expand the pool of professionals in a shockingly broad way who can detain people against their will, which will lead to more holds being placed, not fewer people engaging with officers or people getting better care. Law enforcement, in most nearly all cases, will still be called to forcibly transport the person to a mental health facility.

So more holds, more police calls. Interactions between law enforcement and people perceived to have a mental health disability are dangerous and frequently deadly. 2022 data from RIPA shows that these individuals with mental health disabilities are subjected to force 5.2 times as often as people perceived to have no disabilities.

We're disappointed because it does seem that the author has helpful intentions, which we've explored through many hours of robust discussion with our office about mobile crisis-focused approaches, offering proposed amendments, and making requests for guardrails against this bill being used over broadly, but we regret that because the original bill language remains, we are compelled to ask for your no vote. We pledge to the Senator that we're always happy to work with you on reimagining mental health crisis response. Thank you.

Go ahead. Two minutes.

Good afternoon. My name is Clare Cortright. I'm the Policy Director for Cal Voices. We're a peer-run organization, so we're run by and for people with mental illness, and I'm a person with serious mental illness. I'm also a person that was involved in training hold riders for county designation in Santa Clara County for several years, so I'm fairly familiar with the process and the requirements there.

We're also, you know, regretfully remain opposed to this bill for very similar reasons to the ACLU. We understand that it's really trying to get at two problems. One: we have law enforcement that can right holds categorically. They're primary responders. Those interactions do turn deadly.

Number two is they--police do lack the same level of education as mental health providers and so sometimes those holds are not as of quality as a mental health provider. We just feel that this bill goes in the wrong direction and fails to address either of those issues and will make one of them worse.

Specifically, there's a false dichotomy between mental health practitioners and police with regards to the quality of holds. Our entire court system around holds is involved with getting rid of the ones that were written that were not of quality and were written by mental health providers.

So simply expanding greatly the number of people that can write holds will not address that quality problem, even with the training that is required to have designation. But secondly, we're also authorizing people in their private practice to write holds on anyone, not even just necessarily their patients; out in remote locations in the community.

And we do not have an alternative response other than police to really go and pick that person up, deal with the situation, and transport them to a facility. So authorizing unknown new numbers of people to write holds in disparate locations in the community very predictably results in greater police response, and that just can't be desirable. I don't think anyone here would like that as an outcome, so we ask for your no vote. That's an unresolved issue.

Senator, we're going to pause so that we can establish quorum. Please call the roll.

[Roll Call].

We have quorum at 3:15. Any other witnesses in opposition, please come forward.

Good afternoon. Amer Rashid with the County Behavioral Health Directors Association of California, regrettably in opposition at this time, but look forward to review future language and continued discussion with the author's office. Thank you.

Danny Thirakul, Public Policy Coordinator with Mental Health America of California, in opposition, also on behalf of Disability Rights, California, in opposition.

Seeing no other opposition, we'll bring it back to committee for question and comment. Dr. Weber.

Thank you, Chair. Thank you, Senator, for bringing this bill forward so we can have this conversation. Out there, I already told you I will vote for it today to help it get out of committee. However, I do have significant concerns, and so I very well may not be supporting it on the floor if it continues as is.

My first question is around the issue of police increasing police involvement when we expand the number of people who can do a 5150. So once you state someone needs a 5150 that is involuntary at that point. It is no longer voluntary. And from what I've heard, and also in our analysis, when you're doing transportation for an involuntary hold, the only individuals that can do that is the Police Department.

So how are we expanding--you know, if you expand the number of people that can do 5150s, which would mean that they would need to be transported by police, how are we decreasing police involvement in these situations? Unless what you're saying that our analysis is incorrect.

Thank you. I respectfully actually disagree with that point in the analysis. First and foremost, I do just want to highlight a couple of things. In Alameda County, when people who present a voluntary, present voluntarily or are sent to psych emergency involuntarily by police that are admitted, 72 percent do not fit the criteria, number one.

And for a 5150, you know, specifically by mobile crisis team, 50 percent do not meet the criteria, and yet, for a 5150 with a licensed professional, 25 percent did not meet the criteria. So I do just want to highlight just that range of goals, right?

Overall, licensed mental health practitioners write less 5150s across the board, specifically because they can identify exactly what constitutes involuntary hold and much more. And specifically, two conditions need to be met with a 5150: a mental health disorder and presenting as a danger to others or themselves or as gravely disabled. Right?

With that said, more specifically, this is to have more licensed mental health therapists on the front lines dealing specifically with cases that are escalating with a mental health crisis of some sort. We have actually had the California Chiefs support this bill.

And specifically in our City of--the City of Hayward, we did an internal survey with our police department identifying what do you guys want to be tasked with and not tasked with, and the majority of our police officers specifically stated in that survey that they do not want to handle mental health and homeless crisis calls. Right?

And personally I don't believe that they need to handle it. Right? They are not necessarily trained to the level that a credentialed, licensed mental health therapist is. And the other piece is right now, there are actually transportation being done by non-police officers, ambulance, I believe, EMTs, and a number of other folks.

There's also different models that are being deployed as pilot projects and much more. So, realistically, the sad reality is that our system as a whole, from the county to the city level, has been over-relying on police to do everything in regards to social services. And that's what we're trying to chip away at, and anybody that can have that conversation as to, okay, what else can we do, who else can we fund to do these things both voluntarily and involuntarily with the proper vehicle and much more.

As a health professional myself, I am very well aware of the fact that those of us who are actually trained probably do a much better job than those who are not trained, so I'm not surprised by those statistics, and that really wasn't what I was getting at with my question. Right?

The issue right now when you're dealing with 5150 is that for involuntary transfer, that has to be done by the police. And if this bill takes away the police's ability to do a 5150 and only provides that for professionals, I think that's great, but that's not what it does. It says police, you can still do it, everybody who currently does it, you can still do it, and now we're going to expand it to allow for more people to be able to do it.

And therefore, an effect of that is more interaction for this population with police officers because once you declare that this is not a voluntary hold, if we have a licensed therapist and they're able to come in and really kind of talk that person down and that person agrees to go in, then there's no longer a voluntary hold.

And so then yes, you can send an ambulance or some other kind of transport, but when you're talking about an involuntary hold, having to transport that particular individual to a hospital, that is the duty, the sole duty of the police agencies. Those are the only ones that I know of, at least in my area and also in our analysis, that are able to transport. And so I do have, I do have significant concerns about that part. You know, I know you don't want further involvement with the police. I definitely don't want further involvement police.

I don't think police should be doing this, but this bill does not necessarily remove their ability to provide involuntary holds, so I do have concerns about the expansion for more people which would increase interaction with our police department. So like I said before, I will support it to help get it out of the committee. However, if it's still as is, I cannot agree. I cannot guarantee that I would support it on the floor.

I definitely appreciate that, and again, I do want to highlight that we have seen mobile crisis teams that don't rely on police, even for an involuntary hold, and they have retrofitted and purchased vehicles and much more in the City of Hayward. Our firefighters, for example, are also paramedics, which the HEART Team also works with, so there's a number of different options that are on the table that we are not investing deeper in, and that eventually is the end-all be-all goal. So I agree. Thank you.

Majority Leader.

Thank you, Senator Wahab. I don't take this lightly. You know, it's really important we figure out how we get the best care. My main thing today that I'm concerned about is how you're going to implement this? How is this going to be implemented on the local level? Every community is different, every county is different, and I don't want to be left behind. I want to make sure we all get the same treatment or positive behavioral health concerns and taken care of. So I just wanted to throw that at you, is that I will support it today.

Again, I'm going to be asking you the same question in two or three weeks, whenever we come up with this bill again, is that I need to make sure that we have implementation at the local level.

Definitely. So we have been working with the County Behavioral Health Directors, number one, across the board, and currently Santa Clara County and Alameda County are doing versions of this. So there is a model out there, and, you know, Santa Clara County and Alameda County, both counties I represent, number one, Santa Clara County is very much a leader in this space.

We're hoping that those models are copied and pasted across the state, but as you know and we all know that, as we represent different areas, not every single county focuses on mental health services or social services or do it in the same way. So that is very much a process question as well, and the resources that each county has is very different, right? You know, you have wealthy counties and poorer counties and much more.

So we want to make sure that the counties have still, at the end of the day, the authority, and that's how we've very much modeled this particular bill. So at the end of the day, it's the county's judgment and process.

Mr. Jones-Sawyer.

And then I really do appreciate, Senator, your comments, because I know you began by talking about trying to ensure that we have as limited number of interactions with law enforcement as possible, and I think the purpose, the goal of what you were trying, what you are trying to do is limit that with the number of medical professionals dealing with that. And I think what you're hearing from my colleague, you get different responses to that when you involve law enforcement in different areas.

Not to pick on anybody else's area, but I will tell you in Los Angeles with the Los Angeles Police Department, where someone is not well trained or was retrained in a different way, someone that has a mental health crisis could find themselves beaten and physically harmed.

If there is a law enforcement, if you have Los Angeles Police Department individual who is afraid of their lives, then that mental health individual will not be alive today. And that's what you're hearing from members here, and it's about how do you protect them if you start to bring in or use them to transport individuals, especially if they show up to the scene.

And it's pretty chaotic because their first training or their first response is not what you're talking about from a clinical psychiatrist perspective, but a law enforcement perspective, which is not wrong, it's just different. And then it turns out to be wrong because in that case, it unfortunately may have some devastating impacts on individuals.

And there's cases after cases after cases in my city of that, and so maybe I would suggest you look at those, because I think that's what you're hearing. I don't mean to speak for my other colleagues, but maybe it's a little bit of what you're hearing that what you're trying to do is admirable, but if you could just try to figure out a way to make sure we don't have unintended consequences.

And I do appreciate that, and I also want to highlight a couple of things. Not all involuntary holds are violent--I do just want to highlight that--and not all people with a mental health crisis tend to be violent, right? And granted, when you do a 5150, it's not always pretty. You know, that's the honest truth of it. These are not, you know, happy go lucky incidents or calls or--these are crises. And I do want to highlight some of the concerns that you guys had, for example.

The PMRT, for example, in LA, provides non-law enforcement-based mobile crisis response for clients experiencing a psychiatric emergency in the community. PMRTs consist of the LA County's Department of Mental Health Clinicians designated to perform evaluations for involuntary detention of individuals determined to be at risk of harming themselves or others or who are unable to provide, you know, for example, food, shelter, assistance and things like that for themselves, so gravely disabled in that context.

But PMRT's also enable successful triage of the different situations involving mental illness or a violent or high-risk individuals so they are able to identify that first and foremost quickly, the licensed mental health professionals. Number two is that they are deeply trained in deescalation tactics, number one.

And sometimes you'll have an individual that is seeing things or hearing things and so forth, and these individuals can spot that and be able to deescalate at a more patient level, if you will, than a law enforcement agent, and I do also want to highlight that this bill does not remove law enforcement in regards to every single type of 5150, number one. Number two is that it is the licensed marriage and family therapist or the clinical social worker or the LPCC that makes that call.

911 is always an option on the table, but we want to make sure that there's other options on the table and not the end-all be-all of law enforcement coming in and with their sirens and making a louder and bigger scene. So that is really kind of what the goal is, but I think that there's a lot of misunderstanding of exactly what happens when a call is really made.

And just quickly, the reason why we're moving from PMRTs and away from LAPD is exactly that reason.

Yeah.

Yeah. Assembly Member Schiavo also wants to comment on this. I just want to clarify for the sake of the committee, this bill has nothing to do with police officer involvement, just so you know. I just want to highlight that we spent a lot of time on this bill with the author, our committee staff, and the analysis is spot on and very representative of my particular point of view as well. To be clear, this bill does two things.

One is it adds the LMHP, as defined, to the list of those that are authorized to initiate involuntary holds, and two, it defines what an LMHP is to be a psychiatrist, a psychologist, a licensed clinical social worker, or a licensed marriage and family therapist, or a licensed professional clinical counselor.

The amendment that we put into this bill actually takes a step back, which provides a lot more, will provide the Legislature with a lot more information than it currently has right now. The reality is that we don't actually know what counties are doing, who's designated to do it because the reality is counties can actually designate these types of licensed mental health professionals and others.

There's already a designation process authority within counties and we also don't have enough information about how holds are initiated by designees or peace officers or what the balance of that is. So the amendment that was offered to the author that she accepted essentially lays out a much more--opportunity for us to have a much more data-informed framework from which to be able to make these critical decisions about how we are able to move forward with 5150s.

The author has heard my concerns about this ad infinitum. Thank you for your engagement in our conversation as we considered this bill. I do have an aye recommendation on this bill as it stands now and with the author accepting the amendments with this bill. With that, Assembly Member Schiavo, did you have any other comments?

I just wanted to add, I'll also be doing a courtesy vote today. I want to see how the conversations proceed as the bill moves along. I really appreciate the committee's work and the Chair's work on this and the author's work and really intent, and I think, you know, the concern is not at what is in the policy, but what may be an unintended consequence of the policy. And while we do have, you know, I know you brought up the PMRTs in Los Angeles, which we have. There's 33 two-person teams.

This is a couple of years old, so hopefully it's more now, I'd have to double check, and they get 1,700 calls a month. And so I think the concern is, is there the capacity, and I hear what you're saying is like you're trying to kind of build a path, right? Is what I believe you're saying, right? You want to open this up and build a path in another direction, and we can't build it if there's not a path to it, right? And so I appreciate what you're trying to do.

I also hear the concerns of my colleagues and understand where they're coming from because where those paths don't--I mean, some cities and counties don't have anything like the PMRT, right, and so it would by default be, you know, could be law enforcement or potentially firefighters as well, or EMTs.

But so I think, you know, I share some of the concerns of my colleagues. I hope that there will be more discussions with opposition as the bill moves forward to put some additional guardrails around this, but appreciate your intent and where you're really trying to go with this, and that's why I'll support it today. Thanks.

Mr. Jackson.

I'm only a visitor on this committee, so I'm going to shoot my shot now before y'all kick me off after this. Obviously, I like the bill because it, it simply says the status quo is not acceptable, and we're still in an experimentation mode where what do we, as we reimagine what this happens, what does it finally look like in a way that makes things work? And I would love to work with you next year on a more comprehensive set of bills, particularly with our Select Committee for Mental Health to think about what are those other pieces because there still needs to be more done for, you know, in the Inland Empire, we unfortunately had a death of someone who was experiencing a manic state and lost their life.

And as I read through what happened in my mind, even through a social worker lens, and I know you're going through your training as well to begin to look at what are all those points that we could have done to prevent that from happening? Right? So I think that this is definitely not the end-all, but we got to keep on doing this until we get this right. And it might take us a while, but I commend you for continuing to try to find ways to get at it.

With that, Senator, would you like to close?

Yes. First and foremost, I just want to say that the majority of counties do not invest in mental health and social services to the level that I personally believe is needed, and the options for any random situation that is not being handled currently at the county or somebody that they designate within county and usually mostly employed by the county.

So, meaning the hospitals and somebody out on the street, an average person will call 911, and law enforcement shows up, and usually an incident takes place that makes the news, and that's when we're all upset that something more should have been done. And it's largely communities of color that suffer the most.

And at the end of the day, when we initiated Prop 63 to have prevention and early intervention done by community-based organizations, community-based organizations that hire people that look like them and speak their language, what is the point of doing that and investing in that if they are not able to initiate a process that can protect people, that can save people's lives, and also limit, as much as possible, police involvement? So I respectfully ask for an aye vote. I appreciate all of the discussion here. I will continue to talk to other stakeholders as we have for the past year. So thank you.

With that, we will take a vote on--can I have a motion? Motion by Arambula, seconded by Jackson. With that, please call the roll. And the motion is: do pass as amended to Judiciary.

[Roll Call].

That motion's out 11-0. Thank you. We'll move on to your second item, Senator Wahab, which is item number six, SB 980.

So, this is a less controversial bill. So I appreciate it. I appreciate, you know, the chair and my colleagues here and members of the public, we just actually had our little pressure that highlighted the bipartisan effort of this bill. So SB 980, or the Smile Act, is a bipartisan step towards.

Toward fair and equitable access to dental services for all Californians. It does two things. First, it simply aligns statute to regulations for lab process crowns by lowering the statutory age of 21 to 13, as listed in regulations.

And second, and the most important piece of this bill is this bill adds dental implants to be covered benefit under the medical dental program, 40% of the state, which is roughly 15.3 million people, are enrolled in MediCal. And in order to qualify for MediCal, a family must be at the 138th percent of the poverty level.

The MediCal dental program's current policy might allow for dental implants in very extreme cases, like cancer of the mouth, severe loss of upper and lower jawbone skeletal deformities, or traumatic destruction of the jaw, face or head. But dental implants are not a covered benefit for the average patient in the Dental Cal program.

Yet the program does cover the removal of teeth as well as existing dental implants, but patients do not have an option for replacing them. This leaves patients with holes in their mouth, leading to loss of bone density, lack of jaw stimulation, and weaker surrounding teeth.

Missing a tooth can also lead to oral disease, poor nutrition, and is linked to systemic diseases like diabetes and coronary heart disease. The SMILE act will save millions in healthcare costs through its preventative and early intervention efforts and allow for a better quality of life.

The SMILE act has a considerable coalition of bipartisan, bicameral co authors and support, with over 30 co authors between both houses. This is a common sense measurement that will not only transform the lives of millions of Californians, but ensure the state is properly equipped for its growing aging population.

The SMILE act will allow people to have the dignity of having a functional replacement, to be able to smile, to be confident in that job interview, or on a date, or on a family portrait, or to do something as basic as chewing food.

All of us know someone who is on MediCal and will benefit from this bill. And today I have two witnesses, Bobby Moske, a Member of the California Alliance for Retired Americans, and Cindy Young, Vice President of the California Alliance for Retired Americans.

Thank you. You'll each have two minutes.

Good afternoon, Chair Bonta and Health Committee Members. My name is Bobby Moske and I'm a Member of the California Alliance for Retired Americans. I'm currently on MediCal. I'm here to show you something. Please don't be offended. These are the teeth that I lost. Because dental implants are not a covered benefit under the MediCal dental program.

Though MediCal makes exceptions in a very extreme rare cases, I'm not eligible based on that criteria. Due to the limited benefits offered by MediCal. Over over time, I lost over six teeth in total. Of course I wanted to get implants. The bridge I'm wearing has to be removed before I can eat.

I was told that implants were not a covered option. I simply want to appeal to you as fathers, mothers and family members of kids who may 1 day found themselves in my position. There's a tremendous number of people on MediCal who will end up like this without your support.

My dentist told me the problems with digestion and gum infections were very common after tooth loss, especially for seniors and those who are immunocompromised. Implants would eradicate that problem, and I don't want to present myself to the world without any teeth. Being able to interact in society with self respect is important, but so is staying healthy.

Please allow those who are depending on you to avoid countless digestive problems, serious mouth infections, and most importantly, the loss of our dignity. Thank you for your time.

Thank you. You'll have two minutes.

Thank you. Good afternoon, chair Bonta and Assembly Committee Members. My name is Cindy Young and I'm a Vice President for the California Alliance for Retired Americans, one of the state's foremost grassroots seniors and disability advocacy organizations. Representing over 1 million Californians. We are a proud sponsor of SB 980, the Smile act.

The bill will add dental implants as a covered benefit under the MediCal dental program. As Senator Wahab mentioned, dental implants are not a covered benefit unless there is an exceptional medical condition. When a tooth is lost, the absence affects more than just the visible gap beneath the surface.

The jawbone requires regular stimulation from teeth to maintain its density and health. Without this stimulation, the bone begins to atrophy, leading to a condition known as resorption. This weakening of the jawbone can alter facial structure, potentially leading to further tooth loss and impacts of speech and eating.

According to the Department of Healthcare Services, nearly 40% of Californians are on MediCal. The Department shows that over 14% of these MediCal recipients are seniors and persons with disabilities. The SMILE Act is a step towards supporting our most vulnerable communities, especially the fastest growing aging population in California.

We ask that the Assembly Health Committee votes aye in support the dire need for the SMILE act. Thank you.

Thank you. Any other witnesses and support, please approach the microphone. Give your name, affiliation and position on the Bill.

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

Robert Copeland, California Alliance for Retired Americans, strong support.

Samantha Johnson, on behalf of the California Association of Orthodontists, in support.

Gary Cooper, representing the California Association of Oral and Maxillofacial Surgeons, and we are in support.

Monica Kirkland, on behalf of Senior Services Coalition of Alameda County, we are in strong support.

Katherine Brooks, on behalf of the County Health Executives Association of California, here in support.

Christine Smith, Health Access California, in support.

Beth Manowski with SEO California, in support.

CT Webber, California Alliance for Retired Americans. Yes.

Sumaya Nahar, on behalf of the California Dental Association, we actually have a supportive, amended position. We appreciate the recent amendments, but we.

It's just your position on the Bill. Thank you.

Supportive, amended. Thank you, thank you.

Keith Momoto, Sacramento, California Alliance for Retired Americans, in support.

Thank you. Are there any primary witnesses in opposition? Any others to testify in opposition? Seeing none, I'll bring it back to the Committee for question or comment. Moved by Arambula, seconded second by Jones Sawyer, and he has a comment.

Thank you for bringing this forward. I had periodontal disease. I have the same problem. I know exactly what you went through. And I have dental insurance from the City of Los Angeles and the State of California and still had problems getting things covered.

So I thank you, Senator Wahab, for bringing this, and I thank you for being brave enough to let people know.

Thank you for your bravery. Assemblymember, any other comments from the Committee? I thank the author for bringing forward this Bill. We definitely need to ensure that we have a much broader approach to healthcare overall, but specifically dental health care for MediCal recipients. And with that, would you like to close?

Yes. I appreciate your comments, assemblymember. This is incredibly important. I think that a lot of the bills that are author initiated by me genuinely are about the dignity of all people. And oftentimes we don't see it, we don't know it, we don't experience it, and so it's out of sight, out of mind.

And with the smile act, I think that we can bring dignity to a lot of people who don't feel comfortable enough to smile. So I respectfully ask for a yes vote on the smile act. Thank you.

Thank you. We've had a motion in a second. The motion is do pass to appropriations. With that, please call the roll.

[Roll Call]

That measure's out nine to zero. Thank you, Senator. We are moving on now to item number four, SB 957, Wiener. Thank you, Senator. Proceed whenever you're ready.

Okay, thank you very much, Madam Chair. I'm presenting Senate Bill 957 to address a significant gap in our healthcare system, which is the collection, or lack thereof, of data, health data related to sexual orientation, gender identity, and intersex status.

First of all, I want to note that we have author amendments that are enumerated in the analysis, and we're requesting that the Committee include those amendments. And we appreciate that. Collecting accurate data, health data by demographics, is incredibly important.

If we'll recall back to the beginning of the pandemic, when we realized that older people were much more likely to die from COVID and when we realized that there were much higher rates of infection and death in black and brown communities, the only reason we knew that was because we had demographic data, because when people would go seek health services, they were asked demographic questions, what is your age?

What is your gender? What is your race? Those are voluntary questions. You don't have to answer them, but most people do. And because of that, we could see that disparity. And I'm glad that we were, because it helped with the public health response. And this is true in so many aspects of healthcare.

Unfortunately, historically, we have not asked that question for sexual orientation and gender identity. And it's a massive blind spot in the system. I'm gonna be honest that it's frustrating that I had to bring this bill. I should not have had to bring it.

Former Assembly Member Chu authored two different pieces of legislation collecting this type of data in 2020. I authored a law to require it, and we quickly saw that it was just not happening in the way it needed to happen.

So I requested an audit from the State Auditor, which showed that in a large majority of CDPH forms, the questions were simply not being asked. And so we need to just deal with this issue and not have to keep coming back to the Legislature. And so this bill adopts aspects of the State Auditor's recommendations.

And I respectfully ask for an aye vote. With me today to testify is Dr. Katherine Faubert, associate professor of Women's Gender and Sexuality Studies at CSU Fresno, and Laura Thomas with the San Francisco AIDS Foundation.

Thank you. Please proceed. You'll have two minutes.

Hello and good afternoon, Madam Chair and Committee Members. I am Dr. Katherine Faubert, and I live in Fresno County and an associate professor at Fresno State. I stand here as a researcher and a community advocate for our transgender and queer communities who are often excluded from state and federal research and data collection.

I want to first thank Senator Scott Wiener for his efforts in this. In the Central Valley, there's very little collection on health data on the LGBTQ community, many of who are living in rural and under resources areas, many of who are people of color, and many who have experienced homelessness.

Even though there are wonderful LGBTQ community organizations and activists in the area, without collected data on the population's usage of services and their experiences of health care, social services, and housing, for example, it makes it nearly impossible to advocate for policy change and improvements effectively.

As much as advocates talk about their community experiences, it can be easily dismissed as anecdotal evidence. It becomes more of a question of how big is this population and whether we need to really consider them, further silencing marginalized SOGI communities from local and state government and policies.

Having accurate and collected data on marginalized SOGI populations and their usage is powerful. It gives a clearer picture of the population, one that cannot be easily dismissed.

I have conducted several Fresno County SOGI health and housing assessments to address this lack of data, most notably a transgender health assessment and an LGBTQ health assessment or housing assessment of Fresno County, which showed that barriers to LGBTQ affirming healthcare lead directly to housing insecurity.

Both of these reports are publicly available through Trans Emotion, an organization that I work with. Yep, I'm one person. I'm one researcher, and my efforts are limited in that capacity. This bill will greatly help policymakers, advocates, and healthcare researchers like myself assess community needs and create effective solutions. SB 957 allows for a greater voice for many marginalized SOGI communities, and I respectfully ask your support for this bill. Thank you.

Thank you. You'll have two minutes. Moved by Arambula, seconded by Aguiar-Curry.

Thank you, Committee Members, for hearing this bill. I'm Laura Thomas. I'm the Senior Director of HIV and Harm Reduction Policy, the San Francisco AIDS Foundation in San Francisco, and we are proud to be a co-sponsor of SB 957. And we thank Senator Wiener for his leadership on this and so many other issues.

This bill will close a gap in the law to ensure that California is collecting the data that we need to appropriately target public health interventions. Sexual orientation and gender identity data collection and reporting ensures that local and state health departments, as well as nonprofits such as the San Francisco AIDS Foundation, have the information that we need to identify health disparities. We can't address problems that we can't see, and we have to ask the questions to start figuring out the answers.

This bill may seem like a relatively bureaucratic issue about adding a few boxes to some forms, and that is true. That's a part of it. But it also represents our recognition that sexual orientation and gender identity matters, that these are essential aspects of our lives that can affect how we access healthcare, what kinds of vulnerabilities we have, what our health risks and strengths are, and what we need.

This bill gives us data to ensure that scarce public health resources are effectively targeted to those who need the them the most. In the month of June, recognized as pride month here in California and across the country, I ask for your support for SB 957. Thank you.

Thank you. Any other witnesses in support? Please state your name, position affiliation.

Craig Pulsipher for on behalf of Equality California, proud co-sponsor, in strong support.

Lan Lay, on behalf of Asian Americans Advancing Justice Southern California, in strong support.

Kathy Mossburg, APLA Health, in support.

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

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

Brandon Marchy with the California Medical Association. With the amendments, we are in support. Thank you.

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

Nicole Wordelman on behalf of the Children's Partnership, in support.

Christine Smith on behalf of the California LGBTQ HHS Network, a sponsor of the bill in support and also on behalf of Health Access California in support.

Nicole Morales on behalf of Children Now, in support.

Megan Subers on behalf of the Los Angeles LGBT Center, in support.

Andy Stone on behalf of the HIV Advocacy Network, in strong support.

Thank you. Are there any witnesses in opposition? Are there me toos in opposition? Seeing none. We'll bring it back to the Committee for comment or question. Assemblymember Waldron.

Thank you, Madam Chair. I think this is a very good and needed bill. I served on when it existed, the Select Committee on Infectious Disease in high risk communities, and Assemblyman Gipson was the Chair. I was the Vice Chair, and we traveled around California and we went to various places.

One of the biggest issues we dealt with was AIDS, HIV, especially in some of the urban settings in LA. And what we found was providers were not. I think it was only something like 30% of providers were even up on PrEP and PEP, or even any kind of issue as how to provide the best type of health care.

The more data available to health providers, I feel, the better. We need to look at the risks, what trends, what's the best treatment options, how to get to the best successful outcomes, because we're always talking about data driven care and personalized medicine, and we can't do it without the data. So I think it's a very good bill and I'll be supportive today. Thank you for bringing it forward.

Thank you.

I'll just add, Senator Wiener, I agree with you wholeheartedly that it's unbelievable that we have to be here. And thank you for making sure that we're focused on implementation.

And sometimes it requires a second look and direction provided to, in this instance, the Department of Public Health, to make sure that they're required, as opposed to just allowing them to permit, which, as we heard from our testimony, allows them to not provide us with the vital information that we need to ensure that every part of our California beautiful California tapestry is seen. So with that, very thankful for the bill. Would you like to close?

Thank you. Happy pride. And respectfully ask for an aye vote.

Thank you. The motion has been made and the motion is due pass as amended to Privacy and Consumer Protection. Please call the roll.

[Roll Call]

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

Thank you so much, colleagues.

Thank you. Move on to item number seven, SB 1120. Senator Becker. Please proceed whenever you're ready.

Thank you. Good afternoon, chair and Members. Here to present SB 1120, the Physicians Make Decisions Act, a Bill that takes a critical step forward ensuring fair and accurate health care decisions for patients in California. I'd first like to thank the chair and thank the Committee staff for their work on this Bill.

I will be accepting amendments from the Committee today. Put simply, this Bill requires physician oversight when algorithms are used to decide on healthcare providers requests to offer medical services. We believe this is a necessary safeguard to address the growing use of artificial intelligence in health insurance processes, such as claims and prior authorization requests.

In recent years, health insurance plans have increasingly relied on AI to streamline the processing of claims and prior authorization requests. While these tools have the capability to improve access to care, they face criticism for inaccuracies and biases, prompting calls for oversight.

Lawsuits against companies allege they've used artificial intelligence intelligence algorithms to wrongfully deny essential care to hundreds of thousands of patients. These lawsuits and calls for reform at both the state and federal level highlight the fallibility of algorithm decision making in healthcare today.

We all agree that capabilities of AI are exciting and there are applications in health that can be positive. But algorithm cannot replace the nuanced decision making of a physician by requiring a greater degree of physician oversight. SB 1120 protects patients rights and ensures their healthcare needs are fairly are met fairly and accurately.

And with me I have Doctor Anna Yap from UC Davis Health Emergency Medicine. And for technical questions, George Soares from the California Medical Association.

Thank you. You'll each have two minutes.

Good afternoon, Chair and members. I am Doctor Anna Yap, here representing the California Medical Association as the proud sponsor of SB 1120 relating to artificial intelligence and healthcare. We want to thank the Committee for hearing this Bill today, and a special thank you to Senator Becker for authoring this important measure.

Artificial intelligence is a popular topic that has grown immensely over the past couple years, but in the practice of medicine, we have been using AI for years to assist with diagnosis and testing, which is why the physician community often refers to artificial intelligence as augmented intelligence.

In general, physicians are enthusiastic about the potential of AI in healthcare, but we also want to guarantee that it's done in a safe, responsible and ethical manner for our patients.

SB 1120 takes a step in the right direction by requiring that any denial or modification of care in a health plan prior authorization process must be overseen by a human physician and that any AI tool that is used to support physicians in utilization review processes must comply with federal standards for freedom from bias.

This includes excluding biases that discriminate against an individual based on their gender, race, or other identifiers. AI can be a powerful tool for supporting physicians and making clinical decisions, but we must be aware that they can be deeply flawed.

AI models used by physicians to detect diseases such as cancer or suggest the most effective treatment are evaluated by the Food and Drug Administration.

But the AI tools targeted in this Bill, which are used by insurers in deciding whether those life altering treatments should be paid for, are not subjected to the same scrutiny and have little independent oversight, even though they also influence the care of the nation's sickest patients.

No matter how smart the technology is, it is dependent on the underlying data sources that it learns from. If those underlying sources are flawed or biased, it can cause disastrous outcomes for patients. This is why we need the knowledge and experience of a physician to make the final decision.

This Bill builds on other similar efforts at the state and federal level. In a final rule issued earlier this year called HTI one, the Federal Government put rules in place for certified health information technology tools to ensure that they are free from bias. Several bills currently. oh, thank you so much.

This is a key piece of legislation to allow us to provide some important specific rail guards as AI develops in healthcare. As the leaders of the healthcare team, we bear the ultimate responsibility for treatments that are administered, and it is important that physicians, not computers, can make sure our patients can get the care they need.

Thus, I respectfully request an aye vote on this. Thank you.

Thank you. You'll have two minutes.

George Soares with the California Medical Association here for any technical questions, and thank the author and the Committee.

Move the Bill, moved by Aguiar-Curry, seconded by Waldron. Other testimony in support, please.

Madam Chair and members. Tim Madden, representing the California chapter of the American College of Emergency Physicians, the California Rheumatology Alliance, and the California Chapter of the American College of Cardiology in support.

Madam Chair Members, Dean Grofila, with Capital Advocacy, here on behalf of the California Life Sciences, in support of SB 1120. Thank you.

Vanessa Cajina on behalf of the California Academy of Family Physicians, here in support.

Megan Loper on behalf of the California Hospital Association, here in support.

Samaya Nahara, here, on behalf of the California Dental Association, in support.

Meagan Subers on behalf of CPCA advocates in support.

Thank you. Are there any primary witnesses in opposition?

Madam Chair and members. Stephanie Watkins on behalf of the Association of California Life and Health Insurance Companies, first and foremost, we'd like to thank the author, the sponsors, and Committee staff for working with us with one primary concern that I believe that these amendments address.

So we look forward to reviewing the Bill in print and potentially removing our opposition. Thank you.

Hi, Robert Boykin with the California Association of Health Plans, just echoing the comments of acolyte earlier. Thank you.

Thank you. With that, I will bring it back to, or any other testimony and opposition. Seeing none, I'll bring it back to the Committee for comment or questions. Seeing none, I will share. Thank you so much, Senator Becker, for bringing this forward.

I know that we are needing to make sure that we are providing relevant and helpful guardrails around our AI use, particularly in medical settings. And I think that this strikes a very fine balance to be able to do that. With that, would you like to close?

Thank you. I respectfully ask for an aye vote.

Thank you. The motion. We have a motion in a second. The motion is do pass is amended to privacy and consumer protection. Please call the roll.

[Roll Call]

That measure's on call. Thank you. We are a Health Committee in search of authors. Still remaining to be heard is SB 1147, Portantino, SB 1180, Ashby, and two measures by Senator Umberg. While we are waiting, we will do some business starting with the consent calendar. Can I have a motion moved by Aguirre-Curry, seconded by Waldron.

Secretary, please call the roll and I'll read off for the sake of clarity. Item five, SB 963, Ashby, do pass to judiciary. Item11, so sorry. Item 13, SB 1319, Wahab, do pass to appropriations. Item 14, SB 1333, Eggman, do pass to privacy and consumer protection. Item 15, SB 1382, Glazier.

Do pass to appropriations. Item16, SB 1397, Eggman do pass to appropriations. Secretary, please call the roll.

Roll Call

Consent calendar is on call. We'll move to add ons now while we are waiting. Item number 11. Actually, can we have a motion in a second. Moved by Aguirre Curry, seconded by Schiavo. The motion is do pass to Environmental Safety and Toxic Materials. This is SB 1266, Limon.

Roll Call

Measures on call item number 12, SB 1300, Cortese. The motion is do pass as amended to appropriations. Can I have a motion? by Aguirre curry, seconded by Schiavo. Please call the roll.

Roll Call

Not voting measures on call. We'll move to consider item 17, SB 1447, Durazo. The motion would be do pass to appropriations moved by Agar Curry, seconded by Schiavo. Please call the roll.

Roll Call

Yes, we should do that, shouldn't we? There we go. Thank you, Madam Chair, and especially Laura Flynn for your assistance on this bill. This bill concerns Care Court scholarships. We have a dramatic need for behavioral health care professionals in California.

And what this bill does is this bill basically is sort of structured on an ROTC format where if you give a certain amount of time back to the State of California, in particular, serve as a behavioral health professional in connection with Care Courts, then we will provide you a scholarship. It is a relatively small cohort, but important.

It's important that we set the example. It's important that we provide as well as we can for behavioral health professionals. With me to testify is University of Cal State. Excuse me. California State University, Sacramento student Sierra Fisher. You're here. Thank you very much. And as well as Dr. Erica Rodriguez. So, Ms. Fisher, go ahead. Go ahead.

Good afternoon.

Please put your mic on.

Fisher. I'm the chair of the Legislative Advocacy Committee for Chi Sigma Sigma, the honor society associated with the counseling program at Sacramento State. SB 26 will create an important grant for students working towards a degree in the mental health field, and this is important for California as a whole, obviously.

As a recent graduate, I can personally attest to the need for this legislation. In order to apply for licensure with the Board of Behavioral Sciences, students must complete two semesters of a practicum or internship experience, and my program specifically requires 600 hours of that supervised experience.

Most of these internships are unpaid or incredibly low pay and only part time. So trying to afford cost of living in this state is pretty intense at times. And many students that I know have experienced housing crisis or food insecurity and other types of economic distress. Meanwhile, many counties are desperate for trained mental health professionals.

And I see this as a win-win for both students and for people seeking mental health support in California. Thank you for your time, and I respectfully request an aye vote on SB 26.

Thank you. You'll have two minutes. You have to press the button.

I have to press the button. Good afternoon, Chair, Members of the Committee. My name is Dr. Erica Elena Rodriguez. I'm a full time faculty member of the Marriage and Family Therapy Department and a graduate of the Chicago School of Professional Psychology program. I'm proud to say the Chicago school produces one in every 10 mental health practitioners in California, with campuses in Los Angeles, Anaheim, and San Diego.

Senate Bill 26 is a historic piece of legislation that addresses the mental health crisis in California, a crisis that will undoubtedly continue to increase as we begin to see the fallout of COVID a global pandemic that drastically decreased mental and social support for everyone.

By supporting this bill, we can help alleviate the financial burden on students who are required to complete anywhere from three to 6000 hours of unpaid pro bono work, a burden that stops many individuals from entering the field or choosing employment in our community.

Instead, mental health practitioners often choose private practice due to the limited financial opportunities in our field. It cannot be overstated how important SB 26 to the potential to diversify the mental health workforce.

SB 26 will offer a great sense of relief to individuals who are from lower economic status as first time higher education students, first generation immigrant students who often struggle with being able to pay for their education.

SB 26 aligns with commitment to the Care Court, ensuring that those who cannot control, who can contribute to the mental health system can do so effectively. Many individuals come into the field wanting to give back to the communities that they are from, but find it difficult and often do not offer a sustainable economic path in our communities.

In conclusion, SB 26 means investing into the future of mental health of California. It means fostering a diverse, well prepared workforce ready to address the diverse mental health needs of our communities. SB 26 will allow those with a passion for the field to have a passion to pursue their dreams and to create a sustainable future for themselves and their families.

In many ways, this bill is a culmination of the American dream of being able to achieve a higher education, give back and do more for our communities that we are from, and create a positive future for ourselves and our loved ones.

I urge you to consider the long term benefits of this bill for the state, the counties, and for the countless individuals who will now receive the mental health care that they deserve. Thank you for your time, consideration, and genuine care to invest and the well being of all Californians.

Thank you. Are there others in the hearing room that would like to testify in support?

Good afternoon, Chair. Susan Reyes with the Association of Independent California Colleges and Universities, in support.

Thank you.

Move the bill.

Moved by Aguiar-Curry, seconded by Waldron. Are there any in the hearing room in opposition? Oh, thank you for that. We are doing. We're doing SB 909, Umberg. Oh, sorry. SB 26. Umberg.

We're all confused.

Hello again, Chair and Members. My name is Rachel Bogwood. And I'm a legislative advocate at ACLU California Action. The ACLU is at an opposed unless amended position on SB 26.

We deeply agree with Senator Umberg that we have a mental health workforce shortage and that it can be especially difficult to fill mental health positions that focus on supporting people living with serious mental illness, unstably housed, and facing safety challenges. These are tough jobs, they're often underpaid, and they're incredibly important.

Expanding scholarships for people to work in these jobs at the counties is a great idea. However, we would caution against laser focusing these resources on Care Court. Counties have a mountain of unfilled job postings for licensed mental health professionals and other programs that also serve this population, like mobile crisis response, outreach and case management roles, and more.

These programs successfully serve clients in less restrictive, more voluntary and non punitive environments compared to Care Court. They also have evidence base, huge enrollment numbers and data to back them up. For all the resources that the state has spent on Care Court implementation already, the program hasn't demonstrated much impact or demand, just one data point.

According to the San Francisco Chronicle, after six months into San Francisco's Care Court implementation, the program had received only 22 referrals and nearly half of them had been dismissed. That means it was serving about as many people in the county as are sitting up on this dais.

ACLU has deep ethical concerns about Care Court and also worries that bills like SB 26 are continuing to prioritize this program above others that serve the same deeply vulnerable population and could be more effective with more resources. So let's ensure that any new resources we allocate to workforce for this population have the maximum impact by not unduly focusing on care.

As such, the ACLU will continue to oppose SB 26 unless it's amended to expand the applicant pool to folks who agree to work three years in all county programs that serve individuals with serious mental illness and housing instability, not just Care Court. Thank you.

Thank you. You'll have two minutes.

Greetings, Chair and community members. My name is Danny Thirakul. I am the public policy coordinator for the California Youth Empowerment Network, also known as CYEN.

We are a transitional age youth led program, or TAY led program of Mental Health America of California, dedicated to empowering youth ages 15 to 26 across the state to create and influence mental and behavioral health policy that directly affects them. I'm here today to oppose SB 26 unless amended to more comprehensively address California's mental health workforce needs.

CYEN supports the author's efforts to provide opportunities to enter the behavioral health workforce however, this bill requires scholarship recipients to solely work for county behavioral health agencies to implement the Care Act or Care Court. Care Court is not a diversion program that benefits TAY.

Our youth thrive in prevention and early intervention programs that provide support and services that are person centered, culturally responsive and voluntary. In addition, this bill overlooks the needs of other county programs that are also experiencing a shortage of tab behavioral health workers.

SB 26 must be amended to avoid restricting future tae behave health workers to receive scholarships to work for programs that are ineffective. We should be supporting and uplifting TAY by enabling behavioral health professionals to work with counties and contribute to the many already existing evidence based programs that promote tay recovery and wellness. Thank you.

Thank you. Are there any others in the hearing room in support or in opposition? Sorry. Seeing none.

Sorry. I don't know if I should go up there or not. On behalf of Mental Health America California, also opposed unless amended and Disability Rights California.

Thank you. Wearing a lot of hats today. Appreciate it. With that, we'll bring it back to the Committee for any comments or questions. Schiavo.

So can you--very much appreciate the intent of this, but you know, think the concerns raised by opposition make sense as well. Can you explain the thinking of not having it be more open or broader?

Yes. This is a very limited program and Care Court, and I understand that there's been concerns by some about Care Court, since its inception. Care Court is focused on a very limited population, those with schizophrenia or schizophrenia-like conditions. It is in its infancy and we are trying to make it work.

We are trying to focus it on those who are in greatest need in California, and thus, that's why it's limited just to focusing on Care Court. There's no doubt that we need more mental health care professionals. I mean, that's absolutely clear.

And there's no doubt that if we had unlimited resources, we would provide a scholarship to everyone who wants to be a mental health care professional. We don't have unlimited resources. We have very limited resources. In fact, this doesn't even become implemented unless there's an appropriation.

But we want, I want, and I think those of us who voted for Care Court want it to succeed. In order for it to succeed, we need directed mental health care professionals to make it work. So that's the reason.

Thank you.

Seeing no other comment, I want to thank the author for bringing this forward. I know that you are incredibly passionate about this particular issue, and I appreciate the conversation we were able to have regarding this bill.

And you know that you and I are both aware that funds are very limited this budget cycle, and I encourage you to continue to work with the opposition on the consideration of broadening this to be able to ensure that the entirety of our mental health provider pipeline is addressed. But understand your particular focus on ensuring that Care Court has the infrastructure it needs. With that, would you like to close?

I simply urge an aye vote.

Thank you. With that, we are going to move on to your next item. Oh, sorry. There we have a quorum. Finally. It's moved by. It's already been moved and seconded. The motion is do pass to Appropriations. Please call the roll.