Senate Standing Committee on Health

The Senate Committee on Health will come to an order. Hello everyone. We have 15 bills on the agenda today, with four of them being on consent. I need to go close out EQ and do my votes. So I'm going to hand it over to my colleague here.

And while we did have a special order, we're going to move around just because I have to go do those votes and then I'll come back for SB62 up first. Then we're going to have Senator Allen kick us off with SB682.

Good afternoon. Thank you, Madam Chair and Members. I want to just start by thanking the Committee staff for its excellent work on the bill, and I am accepting the Committee amendments. So PFAS is a large, PFAS are a large class of forever chemicals that persist, contaminate the environment, and have demonstrated harms to human health even at low exposures.

Due to their ubiquity in many, many products, state testing has found PFAS in water systems serving up to 25 million Californians. This bill is a comprehensive and science based approach to phasing out unnecessary uses of PFAS that is intentionally added to products. Specifically, the bill prohibits the sale and distribution of products containing intentionally added PFAS beginning in 2035 unless the Department of Toxic Substance Control determines that the use of PFAS in that product is unavoidable. The Department makes a determination that the use of PFAS is unavoidable based on three criteria.

There are no safer alternatives available, the function provided by PFAS is necessary for the product to actually work, and the product's necessary for the health, safety, and functioning of society. If the use of PFAS is unavoidable, then the manufacturer will receive an exemption from the prohibition for five years, which may be extended if the manufacturer continues to meet the criteria and provides evidence of significant efforts to develop alternatives to the use of PFAS.

Now, certain uses and products require extensive additional research to find an alternative to PFAS as already identified by existing analyses. So under this bill, those uses will be given additional time until 2040 and would also be able to petition for an unavoidable use exemption at that time.

PFAS uses subject to the longer timeline include PFAS used for the manufacturing of semiconductors, fluorinated gases used for certain heating and cooling needs, several other uses that require additional time. And in addition, beginning in 27, the bill bans the use of intentionally added PFAS in products where there are known alternatives and there are bans in other states. So as long as there's precedence, it's working somewhere else.

So these products include things like cookware, certain types of cookware, food packaging, cleaning products, ski wax, dental floss, juvenile products. Other states with similar bans include Colorado, Connecticut, Hawaii, Maine, Maryland, Minnesota, New York, Oregon, Rhode Island, Vermont, and Washington.

We've been a leader in the fight to address the use of PFAS by banning it from a number of product categories right now. Firefighting foam, textiles, cosmetics, certain juvenile products, paper food packaging. But these laws only apply to certain products, and PFAS is still used in a vast array of consumer industrial products that lead to contamination of air, water, food, and human bodies. The EPA finalized a rule back in 23 to limit PFAS contamination in drinking water by targeting six PFAS chemicals.

These standards are set in low parts per trillion level, the equivalent of a drop of water in 20 Olympic sized pools. Which just really reflects the severity of the concerns around this class of chemicals. Beginning in 2019, the State Water Board began requiring testing for PFAS, and it's established notification and response levels for four particular PFAS chemicals.

So to comply with the state and federal regulations, it's important for us to address the source of PFAS contamination on the front end. It's part of why, you know, the water folks are so anxious, including a lot of your water agencies, to pass something like this because they're on the hook right now for all these requirements and yet we've not brought the producers into the... The ones who actually put these products out into the market.

We got to, we got to bring them into the conversation because without addressing the source, we're going to continue to see this contamination continue. It's making it so difficult for our water and sanitation agencies to properly adhere to federal requirements. They're having to increase rates on people to just comply with the basic clean water standards.

So here with me to testify, we've got Dr. Anna Reade, who's here with Natural Resource Defense Council, and also Dr. Max Aung is a professor of population and public health sciences at USC. He's going to provide some testimony on the effects of PFAS on human health.

Thank you. Just before you begin, Senator, are you accepting the committee amendments?

Yes. We are accepting the amendments.

Okay, great. Thank you. So you all will have a total combined five minutes. You may begin.

Thank you. So thank you. And good afternoon, Chair and Members of the Committee. I'm a scientist and Director of NRDC's PFAS science and policy work. To protect public health, we need swift and comprehensive action on PFAS, which are associated with numerous health harms including cancer.

PFAS related healthcare costs in the US have been estimated to be between 37 to 59 billion annually, a burden largely borne by our public. Traditional risk based chemical biochemical approaches have failed to protect us from PFAS, which is why scientists from around the world, including from DTSC, are urging a class based approach for managing PFAS combined with a phase out of all non essential uses.

This bill provides a pragmatic process for implementing these important regulations. All PFAS are extremely persistent or transform into extremely persistent PFAS lasting for hundreds to thousands of years. Because of this persistence, any use of PFAS will eventually contaminate our environment, especially once they make their way into our landfills and our wastewater treatment plants. An example especially relevant to this Committee is non-stick cookware, which involves the use of the fluoropolymer PTFE, better known as Teflon.

Despite claims that fluoropolymers are safe, these PFAS are problematic throughout their life cycle. PFAS contamination from Teflon production has devastated communities across the US, and the PFAS used at these production sites do not stay put. Instead, they spread across the globe and are found in remote regions as far as the Arctic. Heat and abrasion during use and disposal of fluoropolymers have also been shown to release smaller bioaccessible PFAS, further contaminating our environment.

This is just one example of where these harmful impacts can be avoided, as the use of fluoropolymers in cookware is unnecessary and as many safer alternatives exist. We should be avoiding the use of these harmful chemicals wherever possible, and that's the common sense idea this bill would put into effect. We ask for your support. Thank you.

Thank you.

All right, thank you to the Senate Health Committee and Senator Allen for the invitation to speak on the public health benefits of of SB 682. I'm an assistant professor at the University of Southern California, speaking as an individual with research expertise in molecular and environmental epidemiology.

Leading authoritative bodies, including the US National Academies of Science, Engineering, and Medicine and the US Environmental Protection Agency, have established that several well studied PFAS adversely harm human health, including likely to cause kidney and testicular cancer and adverse hepatic, immunologic, cardiovascular, and developmental effects.

Our team has conducted several studies based in California, and we've detected a broad range of PFAS compounds in all of our study participants, including populations that are sensitive to health effects such as pregnant women and children, as well as low income and minoritized residents who face multiple environmental threats.

Building on conclusions from the National Academies and the EPA, our studies have shown that PFAS exposure is associated with liver disease severity, increased risk for type 2 diabetes, lower bone mineral density, which may contribute to osteoporosis and fractures later in life, and several additional cancer types, including cancers of the digestive and endocrine systems, as well as endometrial and ovarian cancers.

I'll also add that cumulative exposure to multiple PFAS is linked with greater risks than individual PFAS compounds alone. Therefore, given that nearly every resident in California has detectable PFAS in their bodies, reducing the future avoidable use of PFAS in products through SB 682 would promote a healthier California by leading to lower exposure levels and lower health risks in millions of California residents. Thank you.

Thank you. We will now move to witnesses who would like to speak in support of this bill. Please state your name, your organization, and your position.

Thank you, Chair and Members. Jessica Gauger with the California Association of Sanitation Agencies. We're a co-sponsor in strong support. I've also been asked to register support for the California Stormwater Quality Association, Monterey One Water, Inland Empire Utilities Agency, Eastern Municipal Water District, WateReuse California, and the California Municipal Utilities Association.

Thank you.

Jennifer Williams with the East Bay Municipal Utility District in support.

Thank you.

Nick Blair with the Association of California Water Agencies in support.

Thank you.

Noam Elroi on behalf of the proud co-sponsors Clean Water Action and Breast Cancer Prevention Partners, as well as San Francisco Baykeeper, Pesticide Action, Agroecology Network, Climate Equity Policy Center, Sisters of St. Joseph of Orange and the Immaculate Heart Community Environmental Committee, San Francisco Bay Physicians for Social Responsibility, Environmental Defense Fund, National Stewardship Action Council, Community Water Center, California Coastkeeper, and Alliance of Nurses for Healthy Environments. All in support. Thank you.

Thank you.

Hello. Keely Morris on behalf of Los Angeles County Sanitation Districts in support.

Thank you.

Good afternoon. April Robinson with A Voice for Choice Advocacy in support of this bill. Thank you.

Madam Chair, Ryan Spencer on behalf of the American College of OBGYN's District 9 and the Environmental Working Group in support.

Good afternoon. Claire Sullivan on behalf of the Cities of Thousand Oaks and the City of Roseville in support.

Nora Angeles is with Children Now in support.

Thank you.

Hudson Pernier with Environment California in support.

Thank you.

Jim Lindburg, Friends Committee on Legislation of California, in support.

LaKisha Camese on behalf of Black Women for Wellness Action Project and California Safe and Healthy Communities.

Kimberly Robinson with Black Women for Wellness in support of this bill.

Good afternoon. Gabrielle Brown with Black Women for Wellness Action Project in support.

Good afternoon. Cassie Gardener Manjikian with Maternal Mental Health Now and the California Coalition for Perinatal Mental Health and Justice in support.

See no one else. Any former opposition to this bill. I think you have a total of 5 minutes form opposition only. Right. We'll get to you after.

Hi, good afternoon. Thank you. Chair and members. Jennifer Snyder, on behalf of the California Life Sciences Association, represents over 1,300 life sciences organizations across the state, all committed to advancing innovation and improving health outcomes. While we appreciate the author's intent to address PFAS related health risks, we must respectfully oppose.

SB 682 is currently drafted as it could intentionally, unintentionally disrupt patient care, delay access to treatment and slow medical innovation in California. PFAS refers to a broad and diverse class of more than 14,000 substances. While the federal EPA has identified six PFAs, others, such as fluoropolymers, play a critical role in protecting public health and safety.

These particular substances are chemically stable, non reactive and highly durable, making them essential to the safe and effective manufacture of medical devices and pharmaceuticals. For example, fluoropolymers are used in catheters, vascular drafts, grafts, heart valves, implantable devices, surgical tools and drug delivery systems.

And furthermore, PFAS is used in cancer medications, vaccines and many critical life saving drugs which we know are rigorously reviewed by the FDA for safety and effectiveness. These applications require materials that are biocompatible, resistant to chemicals, maintain its integrity for many years inside of a body and able to perform under extreme conditions.

Right now, there's no alternatives that provide the same level of safety and performance. While the bill includes an exemption for finished medical devices, it is unclear whether or not components used earlier in the supply chain would also be covered. This ambiguity could create significant risk for manufacturers and disrupt the availability of even FDA approved products.

Even if viable PFAS alternatives are identified, it would take considerable time to test their safety and effectiveness, obtain FDA approval and reconfigure supply chains. We respectfully urge the committee to consider a more targeted science based approach.

Applying blanket restrictions to all PFAs without distinguishing between those that are harmful and those that are essential could severely impact the medical supply chain and limit patient access to care. For these reasons, California Life Sciences remains opposed to SB 682. Thank you.

Good afternoon, Chair and members. Adam Regele, on behalf of the California Chamber of Commerce. In strong opposition, we've tagged SB 682 as a cost driver. SB 682 arguably is one of the most consequential bills you will vote on, not just today, but likely this year.

And I say that not hyperbolically, but because of the vast impacts that this policy if signed into law, would have not only as my colleagues testified in the medical healthcare arena, but in renewable energy, including solar, wind, electric vehicles and electrification of our grid. From home hardening to electrification of our homes to the entire semiconductor industry.

The success of Silicon Valley is at risk because of a policy that is going to outsource the fate really of these entire industries to a single agency, the Department of Toxic Substance Control, both under a scientifically flawed justification and a procedurally flawed process.

I wanted to focus on the science and the then the procedural problems with the currently unavoidable use structure and then talk about the impacts if I have time on a number of different industries that I didn't even outline in my example or fractional list of sectors. So first with the science, as my colleague testified from life sciences.

Treating all PFAS as the same is inherently fundamentally flawed. If you look at the polymers of low risk, there are numerous peer reviewed studies that talk about the physical and chemical properties of these PFAS chemistries. They are not bioavailable, they do not bioaccumulate, they are non toxic, they do not degrade.

And for all those reasons that acidic PFAS that Cal Chambers worked on with the Senator, the author of this bill, whether it was the aquinated fluorinated firefighting foam from a number of years ago to get applications of the acidic PFAS out chamber, has been there on that.

But to treat all PFAS as the same under this flawed policy is going to risk trillions of dollars of sectors under a single agency's determination for highly complex supply chains, whether it's aerospace, national defense, or whether it should be in a pacemaker or inside catheters or inside computers.

We are outsourcing all of our climate change policies to an agency that could basically ban refrigerants that lower global warming potentials. Decades of work could be basically upended by a single agency determination. And not only is it procedurally flawed from that conditional or, excuse me, currently unavoidable use structure. Sorry.

Final thoughts, Final thoughts are this bill will upend California's economy under a flawed scientific and procedural policy. It is why we ask that you vote no today. Thank you.

Me toos. In opposition.

Madam Chair, members. John Winger, on behalf of the Advanced Medical Technology Association, the. National Trade Association for Medical Devices. We're in opposition.

Good afternoon chairs and members. Bret Gladfelty with Gladfelty Government Relations on behalf of AGC Americas in opposition. Thank you.

Good afternoon. Dawn Koepke, on behalf of the Air Conditioning Heating Refrigeration Institute, Chemical Industry Council Of California, as well as the California Manufacturers and Technology Association that has labeled. This a manufacturing breaker. Thank you.

Good afternoon, Madam Chair, members of the committee. Tim Shestek on behalf of the American Chemistry Council, also in opposition. Thank you.

Margie Lie, Samson Advisors. Here on behalf of the California League of Food Producers and the California New Car Dealers Association, in opposition.

Good afternoon. Silvio Ferrari on behalf of the California Building Industry Association, opposition who's labeled this a housing killer. Thank you.

Good afternoon. Katie Davey with the Dairy Institute of California in opposition. Thank you.

Good afternoon. Kelly Hitt with the Plastics Industry Association in opposition. Thank you.

Good afternoon. Sanjida Nahar, here on behalf of Cookware Sustainability Alliance. We are in opposition unless amended. Thank you.

Thank you, Madam Chair. Members, Annalee Augustine, here on behalf of the Sustainable PFAS Action Network, the American Apparel and Footwear Association and Consumer Brands Association. Also opposed. Thank you.

Kelly LaRue with Resilient Advocacy on behalf of the American Forest and Paper Association, in opposition.

Good afternoon. Jacob Brint, on behalf of the California Retailers Association, in respectful opposition.

Good afternoon. Gilbert Lara with Biocom California, in opposition. Thanks.

Good afternoon. Pat Joyce, on behalf of W.L. Gore, manufacturer of Gore Tex, respectfully opposed. Thank you.

Good afternoon. Nicole Quinonez, on behalf of the Household and Commercial Products Association, opposed unless amended. Thank you.

Juanita Martinez on behalf of the Personal Care Products Counsel, in opposition.

Good afternoon. Edwin Borbon on behalf of the Flexible Packaging Association, the Juvenile Products Manufacturers Association and the Center for Baby and Adult Hygiene Products, all opposed. Thank you.

Kasha Hunt with Nossaman, on behalf of the Motorcycle Industry Council, opposed unless amended.

Thank you. Seeing no other me toos in opposition, we're going to bring it back to my colleagues for any questions to the author. Vice Chair.

Thank you. I do have a few questions for the sponsor and author. So I understand that there is an intention to exempt medical devices and pharmaceuticals based on the definition under the green chemistry laws.

And while this is important and supportable, can you kind of help me understand why these chemistries are okay for use inside the human body in pharmaceuticals and heart stents and pacemakers, but unsafe to use in airplanes and electric vehicles and buildings?

Yeah, well, we're trying. At the end of the day, at the end of the day, the core concept of this bill is that we're trying to avoid. We're trying to move away from unnecessary use of PFAs. So the question that we keep asking are, are there safer alternatives?

You know, is the function necessary for the product to work and is the product important. You know, obviously we want to see the medical industry move away from PFAS, from using PFAS that could be ingested into people's bodies.

We're also, you know, sensitive to all the concerns that have just been raised so as to make sure that this doesn't reach the kind of impacts that our friend from the chamber was concerned about, that we do allow all the important manufacturing and development and innovation to continue.

But we want there to be a thoughtful analysis associated with the use of this carcinogenic product.

And so at the end of the day, this is about trying to strike a reasonable balance to ensure that we don't have the kinds of shocks to the, to all the work that is represented by the folks who just got up to speak, while also recognizing the dangers and the need for us to reduce the amount of PFAS in our environment.

And then lastly, through the chair to the opposition, I suppose so what I mean, I would love some elaboration on the potential impacts to our supply chain should this move forward.

The impacts are profound because it bans not only the products, the components, but also manufacturing equipment. The definition of intentionally added has no thresholds. And so the mere iota of PFAS in your supply chain could end up getting your product banned.

The process or procedural flaws of this is you are going to have hundreds of thousands of petitions into a single agency that historically has not shown to have their resources or staff to be able to handle that. So we agree there needs to be a thoughtful approach.

We do think the science needs to be based on the PFAS chemistries that do bioaccumulate are harmful to human health. Treating the entire class the same from the outset is a problem for the entire supply chain.

A lot of who you've heard from, whether it's the medical or other folks, are using floral polymers and so to be treated the same as the acidics we think is highly problematic. And then to have the agency get through this process and also has the ability to regulatorily move up the dates.

The dates you see in the bill we do not see as static. They can move it up if, quote, feasible. So as an industry, your entire supply chain is at risk of every five years having to get this exemption. And in fact, those dates could be moved up on you.

You cannot invest in the state, and you may not want to stay in the state if your fate of your entire product is to a single agency every five years.

Mr. Senator, I genuinely appreciate your intent with this bill, but there are just so many unknown and known ripple effects that I just can't get there. But happy to have conversations with you in the future. Thank you.

Appreciate it. Yeah.

Senator, go ahead.

Thank you, Chair. I want to thank the Senator for, you know, bringing up this bill and continuing the conversation of PFAS, which we all know has significant health detriment.

One of the things that I did find interesting in this bill is the fact that many of these regulations will not actually go into effect for another 10, 15 years. It's really hard for me to imagine in 10, 15 years that we as a society would not be able to come up with an alternative that is safer.

I think if we were talking about something that was going to go into immediate effect or the next 2, 3 years, that would be very, very challenging.

But, I mean, medicine technology is moving at such a rapid pace that I find it really hard to believe that we wouldn't be able to do this in the next 10, 15 years. And I'm so that's one thing.

The other thing I'm a little confused now because I was hearing that this was going to have significant impacts in the medical field.

But then Senator Valladares just asked about, like, stents being allowed, and I'm looking at the analysis and it talks about the fact that, you know, prescription drugs and medical devices and their respective packaging are exempt.

So through the chair, I was wondering from the opposition if you could explain to me exactly how this is going to impact health and health outcomes.

So thank you, Senator, for the question. I think the concern is, yes, we are. We clearly know that the bill exempts finished medical devices, finished drug delivery systems.

The concern for us and for the California life sciences is that it has an impact on the supply chain that provides the components of that device or the components or the ability to manufacture that device. And there is not a clear outline in the legislation about how to address that.

And I do completely understand that your comments about over time, maybe we can find some alternative. And I know that as medical community is always looking for ways to provide devices and drugs that are the most safe for patients.

But I think the entire supply chain is subject to, as you know, very well, rigorous and lengthy process of going through and trying to address that. And so through the FDA and other requirements.

And so we're really concerned about not only how this will affect the supply chain and everybody that's providing the components for the device or the drug delivery system, but exactly how long it's going to take. Right now, we don't have an alternative. So we just, we can't estimate exactly when that would be.

And so that's the overall concern.

Completely understand. Just out of curiosity, have you provided any potential language or recommendations to the author on how to ensure that when they say prescription drugs and medical devices and packaging that that actually truly includes everything that you're talking about so that it's very clear?

We have not yet. We have discussed that internally. It's just, I think the concern is of the amass of that concept and how to actually address it and have the assurances within that language. I don't know. Adam, if you want to add to that.

Sure. Through the chair. So fluoropolymers is the industry innovating to find things that can provide the thermal insulating? If it's talking about a pacemaker, you put it in there, you go in. Once you add that pacemaker, you don't have to go back in for 30 plus years. Again, it doesn't bioaccumulate, isn't bioavailable.

It is all the properties that the acidic PFAS, which again Cal Chambers worked on to phase out of other sectors, that is the innovation. And so the Vice Chair made a great point about if it's safe to put inside your body, stents, oral medicines, why are we banning cell phones, semiconductors, computers?

If those things as we've been communicating, oh, you'll get the exemption, then we should have that discussion at the front end. Not putting entire sectors into the process with one agency's gonna have to make a determination of it.

And so we have problems with the fundamental concept that one agency is going to dictate the future of many, many sectors beyond. And we 100% support exempting medical for the same reasons why other sectors should get it as well.

Yeah, no, I understand that. I don't think I got the sense that the author was stating that these products are safe in the body. I wouldn't go that far to say that as a physician, but I understand that this is a process of working together, collaborating and sometimes making concessions. So I don't know, was that what.

You know, I have not suggested it's safe. It's just that we see the balance of the value associated with the kinds of devices that you're talking about. And we're certainly, we have no interest in jamming up that important life saving work too. I mean, unfortunately, we've dealt with this for a long time with firefighting equipment.

We know that a lot of the foam is dangerous on the long term, but we also know that the firefighter needs to survive that fire in order to even have the chance to get cancer later. I hate to phrase it that way, but that's kind of the situation that we're facing here.

So we certainly don't want to do anything that would harm the folks here doing their important work, the life saving work of those devices that make a big difference immediately for people.

But I think it is also our strong hope that over time, as you stated so clearly, Senator, that there will be adequate research and development that will allow us to move toward safer alternatives.

Thank you so much for the questions. And a lot of the concerns are coming from the opposition, you know, are better suited to be had in discussions related to the EQ Committee. And a lot of of the requests that were given to the EQ Committee and the chair was a hard no for them.

And it doesn't fall under a purview or jurisdiction here in the Health Committee. What we didn't want to have was one or two exemptions after those conversations already had with EQ. Now I recognize and I sat on EQ and I didn't have the opportunity to share some of my opinions on the EQ world.

And I know those conversations still need to happen on the assembly side. But as the health purview, it's a little limited. You know, we don't have that DTSC Department that you speak about. We don't have a purview over the five year review which still. There is an off ramp.

Exactly.

There still is an off ramp. To have the ability to come and bring explanation as to why there is another option available. This isn't a you figure it out or you're screwed approach. This is, we want you to figure it out.

And if you can't, we're providing an opportunity for you to provide to us proof that you can't get to that point.

And I understand that the author was looking to balance and I think he did a good job in responding how some things were exempt because those are more sensitive items, which is why I'm recommending I vote and I'd like to give you an opportunity to close.

Yeah, I really appreciate the discussion and I will say, I want to say very explicitly, we, you know, we see that, that you know, the bill is permitting supply going into medical devices, pharmaceuticals, animal, you know, animal products also exempt.

So you know, we've, we have asked, and I respect the fact you've got an internal process, we've asked for amendments to make sure that that's really locked down. So we certainly don't want this to be used as some kind of, you know, we're only, you know, impacting the finished product.

But we're not, we're not being flexible with you on the, on the supply chain side because that's, that's useless. So please get us some amendments.

I mean, the one caveat I will say is that it's difficult for us to just provide a broad exemption for everything produced by those suppliers since they may provide supplies, products other than medical devices and pharmaceuticals. So that's the one thing that I think is going to take some time as we try to figure it out.

But at the end of the day, we've crafted a system that, that's saying this is about unnecessary use. We want this to be flexible, we want this to be workable. But we also recognize the fact that we've got to push industry.

Unfortunately they got to be pushed to move off of this dangerous chemical that is so effective and so powerful because it's so dangerous, because it's so effective, so powerful, it's so strong chemical. And that's what we're seeking to address here. And I, you know, respectfully ask an I vote.

I want to thank the committee for all the work that it's done and look forward to continuing to work with you.

Great, thank you. When we have a quorum, we'll entertain a motion. Senator, you can move on to file item nine, SB 812.

Thank you. Okay, less controversial, here we are. Okay, thank you everybody. Appreciate it. Let me start by again taking the Committee amendments. You know, many young Californians face serious mental health challenges and many are unable to access timely stigma free support.

Youth drop in centers are an innovative model that provides safe, welcoming spaces for young people to receive no cost medical care, mental health care. Sorry.

California has launched the Children and Youth Behavioral Initiative or CYBHI to ensure kids and families can find support for their emotional, mental and behavioral health needs when, where and in the way they need it most. The CYBHI also created a fee schedule to reimburse costs for certain outpatients and services with no out of pocket expenses.

Currently only schools and colleges are authorized for Bill to Bill for services under the fee schedule. And we've got these wonderful youth drop in centers that then have to go through this burdensome individual contracting process with schools just to serve the students and be reimbursed. It's crazy. They're oftentimes doing the hard work of serving disconnected youth.

These are young people oftentimes who may not be comfortable seeking care at a school surrounded by their peers and their teachers and everyone else, and they may feel more comfortable in a neutral, supportive setting off site. So these are essential centers, but they currently lack a sustainable funding model.

So we're seeking to address this issue by allowing youth drop in centers who are designated by or embedded in local schools and colleges to directly bill health insurers under the fee schedule.

It provides a sustainable funding model for these vital services and it also will expand access to to confidential stigma free care, especially for vulnerable youth who may not be in school or college. This is a practical fix that ensures that this care reaches the young people who need it the most.

And here with me today from a really special institution in the southern portion of my district, the Beach Cities Health District, we've got Ali Steward, who's the Chief Partnership Development Officer there, and then also Kylie Charafen Horvath, who's on this wonderful youth advisory board of young people who provide guidance and support and input into the work of the Alcove Youth Drop in Center, which is a wonderful facility in my district that provides a special safe place for kids to come and receive support.

So I'll turn it over to Ali.

Thank you. Good afternoon. My name is Ali Steward, on behalf of Beach Cities Health District here in strong support and as sponsors of SB812.

Go ahead. You have a total of five minutes.

The Beach Cities Health District is one of 77 public health care districts in the state working to support the unique health needs of our communities by serving vulnerable and underserved populations and addressing critical gaps in care. SB812 is critical to filling these gaps. We are the lead agency for Alcove Beach Cities in Redondo Beach.

And our Youth Drop in Center has seen more than 11,000 visits since opening in November 2022 by young people ages 12 to 25, with more than 1,300 enrolling in service services. We provide free mental health and physical health services, substance use prevention, peer and family support, and supported education and employment.

The Growing Alcove Network is funded through California's Behavioral Health Commission and the CYBHI. Importantly, it is designed by and for youth. And you'll hear from one of our youth leaders today. As the Senator mentioned, SB812 clarifies existing law, leveraging the fee schedule to offer clarity and consistency in payment for services.

In addition to this bill, we look forward to working with the Department of Healthcare Services to amend the guidance recently issued for community providers. Both are critical to ensuring service lines remain open for the young people across California.

We know there is an urgent need for accessible mental health services for young people and SB812 ensures a no wrong door approach. We are working with 13 school districts to support them in onboarding to the fee schedule and we believe that both schools and youth drop in centers form a continuum of care for young people.

When schools are not in session during breaks, holidays and summer, Alcove Centers and other youth drop in centers can ensure students continue receiving these services. Additionally, we've heard from many young people, especially those experiencing homelessness, system involvement or family instability, who may not be comfortable accessing services in a school setting.

Drop in centers are trusted, low barrier spaces where young people already seek help. SB812 fully aligns with the CYBHI billing practices without copays, ensuring affordability for all young people. For these reasons, we respectfully request your support on this important measure. Thank you.

Okay. Good afternoon. My name is Kylie Sharfen Horvath and I've been a Member of Alcove Beach City's Youth Advisory Group for the past two years. I'm also a senior in high school at DA Vinci Design and I'm incredibly grateful for this opportunity to share my perspective with the committee and my support support for SB812.

So I first got involved at Alcove after struggling with my own mental health for many years. During this time, I had observed the collective sense of isolation my peers and I experienced, and this sparked my devotion to fostering an environment where adolescents could feel seen and supported.

During my time as a youth leader and advocate for mental health, I've witnessed what an important role Alcove plays in my community for both crisis intervention and prevention.

While helping young people navigate healthcare systems and payment models, sometimes for the first time on their own, centers like Alcove also give young people the autonomy to access care on their own terms.

This allows youth to receive the support they need in an environment where they are comfortable and can build a community with like minded individuals also seeking similar support. While my peers and I can collectively agree that we're thankful to have mental health resources available at school, they're not always comfortable or easy to access.

There's often a stigma that follows being called out of class to go to the office, and many of my peers worry that their personal information regarding their mental health, which is something incredibly private, will become common knowledge to their classmates, making them reluctant to access resources on campus.

Not to mention, if a risk assessment happens at school and transportation by ambulance is needed to the emergency room, this is both traumatizing for the person involved as well as expensive for the healthcare system.

This is why it's important that we continue to support centers like Alcove that provide young people with a safe space off campus where they can access the services that they need, when and where they need. If youth are given this access and autonomy, it will help us to break down the stigma that continues to surround mental health.

Thank you for your consideration of this incredibly important Bill that I believe will help youth centers in California flourish.

Thank you. Now is the time for me too's in support.

Thank you, Madam Chair and members, Sarah Bridge on behalf of the Association of California Healthcare Districts here in proud support. Thank you.

Kelly Larue with Residents Resilient Advocacy on, behalf of Hazel Health of California, a. Behavioral health provider for telehealth for kids in schools. Thank you.

Thank you. Any formal opposition? Any me too's opposition?

Hi, I'm Olga Shilo with the California Association of Health Plans. We do not have an opposed position, but we did issue a letter of consent concerns. We appreciate the amendments and we are confirming whether they address these concerns and look forward to continuing to work with the author. Thank you.

Thank you. I'm going to bring it back and I'll kick up the conversation here because this is an issue the Senator knows I've been working on for a couple years. I just want to clarify some things. I know you know Alcove, you've provided services under the CYBHI, the Children's Youth Behavioral Health Initiative.

But just because you're providing care under that program does not mean that the fee schedule is a sub program of that, that is allotted to you. The whole point of the fee schedule and to the Senator's point on this was to provide services on school campuses.

And I know the Senator mentioned that, you know, what if kids don't feel comfortable providing or getting therapy or services on a school campus? Well, that was the whole premise of the fee schedule was to only provide and help schools be able to provide claims for the services taught on school campuses only.

So it was very specific about that.

I had other concerns with the Bill which is why we pushed it over to this week because truthfully I was a no in the beginning with this bill because what we're seeing right now is and what we're going to hear in sub 3 tomorrow Budget Sub 3 Committee, is that since this was implemented almost two years now, the fee schedule has had a lot of hiccups in providing payments to the schools in there.

In that short time there's only been approximately 163-160 claims, $20,000 worth and the Department has only paid $4,000 worth of the $20,000 worth. Schools are laying people off right now because they hired them under the fee schedule program.

What I didn't want to do is further burden a program that was struggling right now with adding additional entities into the program. So the amendments that I provided I think helped to address that.

Only if a school partners and determines that they want to allocate a child or refer a child to a non profit CBO to provide that service. That's the only way we could include in the fee schedule.

But this program is having a lot of problems and I already have are dealing or I am already talking to a lot of stakeholders that are very concerned. I didn't want to add other concerned stakeholders to the mix. So I just wanted to explain where my trepidation was coming from and my hesitation on this Bill.

The overall arching goal to provide services to youth, 100% on board. That's never the problem. But just want to make sure that we allocate those kind of services to, to programs that have the capacity to help and are not struggling.

So I am supporting this Bill now, but just wanted to paint the picture of what's happening with the fee schedule program. Vice Chair

So I know they weren't in opposition, but I would like if we have someone from the healthcare plans. I have some concerns and I need some clarification before I decide on where I'm gonna vote today.

I know in their letter that they sent it seems like there may be some questions or concerns about continuum of care. Specifically that they say that mandating coverage outside of the plans or insurer's existing system without referral or coordination could lead to a significant fragmentation of care.

And I just have concerns if we're going to be treating, diagnosing that I would just hate to for something tragic to happen because there's not a continuum, continuum of care plan in place. So I'm not sure if anyone from health care plans are here that could help me understand this.

Feel free to come back up if you wish to answer this question. You don't, you're a concern so you don't, you don't have to.

We issued a concerns because of, you know, the remarks that the Chair made. The program is so new and the intent behind it, what it was. And so, and that's what it was. The concern. If we're going outside of. We don't know what the, like what it meant, how it would work in reality.

If kids are going outside of the school system and there is no awareness of coordinate like no opportunity for coordination of care. So we are concerned that that was a concern, but primarily it was with the CYBHI fee schedule not being ready to go and the delays.

So to the witnesses in support is. I mean, is will or the author will. What are the stop gaps to prevent this from happening?

I think if I can. I think the amendment was looking to address that because without the amendments, it was just any individual could go to a drop in center and then they can make a claim. Now, with the amendment, the student has to be a specific school who already has that fee schedule. Right.

And the school has to make the referral. Has to have a contract. Sorry, has to have a contract with the youth drop in center. So because they have that contract, they can refer that student to the drop in center.

So we were trying to find a nexus where it was a continuum of care where they came from a specific school that could put in that claim to the fee schedule.

Okay.

Senator, if anyone else wants to add to that.

No, that's exactly right.

I mean, you get that, right? Yeah, yeah, yeah, yeah. But I mean if there's. I still have concerns. We're certainly going to be interested in hearing from the. The folks who raise concerns if there's some additional changes that need to be made. Happy to consider. Yeah, because we. I know we all share these, these concerns.

Yeah, no, I mean this is. Yeah, I think everyone here gets what we're trying to do and I appreciate the chance to continue working on this. Ask for aye vote.

Senator, you may close.

Thank you so much. When we have quorum we'll entertain a motion.

Yeah. Thank you.

Thank you. We will now be moving to our special order file, item number one, SB 62. Senator Menjivar, when you are ready, you are recognized.

Got really lonely up here.

I really wish other colleagues would be here because this is a big, big thing and. Yeah. Okay. Well then, Vice Chair. Time and time again this committee has reviewed, voted on mandate- coverage mandate bills that exceed the essential health benefits.

And if you didn't know about the essential health benefits like I did in a couple years ago, you'd be frustrated as to why, why do they. Why did the Governor veto hearing aids for kids? Like that is so evil. In fact, it's because we couldn't really add those to our plan.

Unfortunately, for small and individual plans, we can't simply just add coverage on a case by case basis. Coverage mandates for those plans must be done through a review of our essential health benefits that are then approved by the federal government. So finally, after years of these kind of bills getting vetoed or held in suspense.

Both health chairs introduce legislation to begin the process to update our current essential health benefits to see what could be added as mandated coverage. Since then, two public health meetings for stakeholder input occurred. Earlier this year, this committee, along with the Assembly Health Committee, held a joint informational hearing to talk about the analysis, cost impact and timeline.

We acknowledged that we weren't able to add everything that was being requested of us because we have a structural cap of what we can add, and that cap is at 2.2- 2.23% of estimated cost insurances, meaning whatever we added couldn't go higher than that. Therefore, after careful discussion, an agreement.

A tentative agreement was reached to include the following: hearing aids for everyone, including children, durable medical equipment such as wheelchairs, personal mobility devices and a personal favorite, infertility diagnosis and treatment, including IVF.

On March 28, the Department of Managed Healthcare announced that the benefits described in this bill were open for public comment and they were getting ready to submit to the federal government. Adding these benefits marks a huge step forward for people with hearing loss, people with disabilities and people who are struggling with infertility.

But I don't ignore the fact that by adding these mandated coverage means that people's premiums are going to go up. Chapurb analyzed that there could be an increase of potentially $8.55 per member per month in premium for- their premium plans for silver plans.

Colleague Senator this will give a child who is hard of hearing or deaf hearing or deaf, hearing aids that currently cost parents thousands of dollars every three years. This will cover fertility services for people who otherwise would have to pay tens of thousands of dollars. It's a trade that I believe is completely worth it.

DMHC has until May 7th to submit our plan. And SB 62 would codify the addition. These three additions to our California Essential Health Benefits if approved by the federal government and it would start in the year 2027.

Now I'd like to turn over to the department who were so gracious enough to come and speak on the- on the essential health benefits.

Thank you. You are each recognized for two minutes. Two of you.

Okay, great. Thank you. Mary Watanabe, Director of the Department of Managed Healthcare. Sarah Rehmer, Chief Counsel is here with me to answer any technical questions. I'll be very brief. I won't repeat anything that was already mentioned. I will just note we had a series of public meetings, took a lot of public comment.

Appreciate the very thorough comments that we received. As noted, on March 28th, we did release the draft document we planned to send to CMS to update- update our benchmark plan for one final comment period. Based on the comments we received, we are making two non substantive updates to the documents.

First, we're updating the Actuarial report to clarify that fertility services will cover donor sperm and eggs for both artificial insemination and in vitro fertilization.

We're also updating the summary document to clarify that health plans are required to cover behavioral health services when provided by physicians or other providers who are licensed healthcare professionals acting within the scope of their license, which includes trainees and associates who provide services under supervision.

The DMHC has the administration support to move forward with submitting California's application to CMS by May 7th. As noted, the cod- the legislature will need to codify the benefits in statute, which is the subject of SB 62 and these benefits will take effect in January 1st of 2027 if approved, and again, Sarah and I are happy to answer questions.

Thank you. Diana Douglas With Health Access California we're pleased to support SB 62, which as we heard comes after a year long process to solicit stakeholder feedback on potential updates to our state's benchmark plan. We believe the new required benefits would provide significant benefits to consumers in California.

Health Access was part of the process of developing the original EHB standards back in 2014-2014. At that time we knew that not everything consumers needed or wanted was included, but it was the most comprehensive benefit package we could develop under the rules then.

In the decades since, rules have changed, we've seen that California can lead the way in higher standards and we have the opportunity to provide more extensive benefit package. SB 62 includes hearing exam and hearing aids every three years so fewer Californians will go without hearing due to lack of coverage.

The inclusion of durable medical equipment including wheelchairs and oxygen equipment will help consumers who often face limited coverage and out of pocket costs skyrocketing up to $50,000. These people often go without their devices or use inferior ones.

And finally, the infertility coverage, including IVF will have a significant impact on people facing fertility challenges and also an equity impact on the LGBTQ community. Health Access appreciates the careful consideration of the full range of benefits to include in our state's next benchmark and we ask for your aye vote on SB 62. Thank you.

Thank you. Now is anyone would if anyone would like to express their support, please come forward. Name, organization and position.

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

Eric Dowdy with the California Dental Association we're support if amended, urging the inclusion of dental when we can.

Ryan Spencer with the California Association of Medical Product Suppliers in support.

Sumaya Nahar with the Children's Specialty Care Coalition. In support.

Nicholas Brokaw, on behalf of the California Academy of Audiology in support.

Johanna Wonderly, parent of four deaf children. In support. Do you want to say? He says hearing aids.

Mala Jay with SEIU California in support.

Hi. Good afternoon. I'm Dr. Ruben Alvero. I'm part of American Society for Reproductive Medicine. I'm also registering support for the Alliance For Fertility Preservation as well as Resolve, which is the national fertility organization. In support. Thank you.

Maria Esherich. And I would like to thank Senator Menjivar for adding hearing aids to the EHV benchmark. Thank you. In support.

Michelle Marciniak of Let California Kids Hear and Marie's mom. In support. Thank you so much.

My name is Tremmel Watson. I'm in strong support and would like to thank the Senator for pushing this bill forward. Thank you.

Nora Angeles with Children Now in support. And grateful to Madam Chair for her efforts. Thank you.

Alex Smith, parent of a hard of hearing child. I support. Can you say I'm Smith I support? He just woke up.

Kimberly Robinson with Black Women for Wellness Action Project in support.

Thank you. We will now move to any key witnesses in opposition. If you'd please come forward.

With your indulgence, Chair and members. Nick Louizos, this with the California Association of Health Plans. We're not in opposition. However, we did issue a letter of concerns regarding the timing of this. We have argued to delay this project for a year pending the outcome of federal budgetary decisions, particularly the ACA coverage subsidies.

If those go away, that will lead to coverage losses and affordability impacts. So we're concerned about that. And this package does increase premiums according to Wakely by 2%. And so that'll further exacerbate the problems if things go awry at the federal level.

So, you know, we encourage to put this project off for about a year pending those outcomes. Thank you.

Is there anyone else in the room that would like to express their opposition? Please come forward. Seeing none, I'll bring this back to the committee. Senator, you are recognized.

Thank you. Chair want to thank Senator Menjivar for bringing this bill forward so we can have these conversations. You know, was happy to see that the hearing aids were included. I know that's been a long. I don't say battle, but, you know, conversation. I know it's something that you've. You've carried a bill on in the past.

I am very much in support of including these things in our essential health benefit.

I am very concerned, though, about the timing and seeing where we are in a huge budget deficit in our health at this current moment without knowing what's going to happen at the federal government levels and then not knowing what this administration, who has not been, who has not acted in the best interest of American citizens when it, or people who live here in the United States when it comes to their health care coverage.

So far, I'm very concerned about the subsidies issues that was brought forward before and the overall rise in the amount of out of pocket expenses that individuals will have to pay when affordability is already such an issue. My question to the witnesses, if this bill goes forward, are we able to stop the ball rolling?

If we find out in September, October, November, December, whenever we find out that, you know, we no longer have the subsidies, that, you know, many people will be losing their health insurance based on what this current administration may do, are we able to stop it at that point or is this kind of like what we'd have to do because it would be passed and potentially signed?

Yeah. I'll start and Sarah can add. So obviously there's a lot of unknowns with the federal administration. Typically there is more back and forth than what we've had. We have had some informal conversations with CMS. Typically in a, you know, a typical year, maybe a few years ago, we would have a decision usually around the fall.

So that kind of aligns with the date you're talking about. So there is the option, we understand, to withdraw our application. So it'll just depend on where we are in the process. But that's, you know, a lot of unknowns.

I think our plan is to move forward with filing, see the questions they have and then go from there.

I don't know, Sarah, if you'd add anything. So let's just say that, you know, what we hope doesn't happen at the federal government happens.

Where in the language of this bill does it state that if, you know, we end up losing our subsidies, if it's not, if they approve the EHP, but if these other things happen, that we would halt, that we wouldn't go forward, that we'd have further conversations like how do we pull it?

Like, where does it say that we could pull it back?

Yeah. So Sarah, you can jump in here, but I believe the language of the bill ties it to CMS approval. But go ahead.

It does. Director Watanabe is correct. So if we were to, we submit the package to CMS, they have not yet approved it and we learn that we're going to be losing subsidies and we withdraw the package, the bill is contingent upon approval by CMS. So in that instance, our currently existing benchmark plan would continue.

We would not be replaced. If CMS has approved the benchmark plan though, then that would be the plan that would take effect January 1st of 2027. We would likely not have the ability to revert to. To the existing as of today benchmark plan.

Okay, but the language is based on CMS approval of the essential health benefit plan, not the subsidies. So there's nothing in the language that would state even if you know.

Yeah, but Senator, we will know long before the subsidies expire at the end of this year. So we would know and we can 100% come back. But what if they had approved the plan by then?

Then we wouldn't be able to pull it back.

Likely not. So that would be in. We would be in some uncharted territory. CMS has. We actually inquired about that to CMS, but we have not received an answer to that question as to what happens if CMS approves the benchmark plan and we decide we don't want to move forward.

So my assumption would be that once that benchmark plan is approved, that will be the benchmark plan for California.

Even if we find out before we find out the information about the subsidies. Correct.

And so Senator, just to clarify though, this bill still needs to be presented to the Governor for signature. So there could be some lapse of time that would give us. Yes. That flexibility. Yes. Okay.

I'll just note. Sarah and I were sidebar really quickly. I think we could start the process again to set a new benchmark or made changes, but it wouldn't take effect in 2027. You have to file by early May each year for it to take effect in the future years.

So it would be 2028 at the earliest if we were to make changes. But that would kind of be another option if we were to change the.

But we don't know if the federal government or CMS is going to change the process or if this administration is going to change the process for us to change our essential health benefits, which is why we're trying to do this now given the current process that we know right now.

Yeah. So many unknowns. So, Senator, do you. Let's just say that we find out that we've lost our subsidies. Would you be willing to not go forward with this bill or would you still.

Senator, this isn't. This is being carried by both health chairs in each house. Right. This is while not an author driven bill, this is a collaboration amongst the three. Both houses and the governor. It wouldn't be solely on my decision to pull back. It'd be a collaborative decision after looking at everything.

So I can't commit by myself because it'd be in collaboration with the department, the governor, and the assembly. Okay, thank you.

Well, first of all, I want to thank you for all of your hard work on this, your bipartisan work, you know, reaching out to me and to my office early on to talk about priorities. It's genuinely appreciated. You know, I have a special place in my heart for individuals with special needs.

And anyone who knows me knows that. I tell the story of my niece who was diagnosed on the autism spectrum when she was two and a half years old, about that journey from her diagnosis, early intervention from her getting glasses.

And so for me, anytime you have a special needs child or adult who needs a device for quality of life purposes, just to do the basics that is near and dear to me, I want to thank you for including and being a champion for providing hearing aids to people who need them.

I do want to say, though, and it's always obviously very hard for me to support policies, bills that will increase healthcare cost or premiums, and it is a delicate balance. And I think you did a really good job of trying to prioritize that.

I will agree with my colleague from San Diego that we have some serious conversations and discussions that we need to have around California's healthcare spending. Despite despite whether or not the federal government cuts makes any cuts to our dollars, we're bloated here in California. I think we have $8 billion deficit in health care spending.

So we're going to have to have deeper conversations. But it is about expressing our values through our priorities. And I think this bill does that. So I'll be supporting it. And thank you for working so hard on it. We don't have a forum. So close. You may close.

Thank you so much. I appreciate it. You're right. In my short time here, I've been able to connect with stakeholders of the three items that we're looking to add to essential health benefits. And I know it's a heavy decision to make to say in a time where a lot of Californians are struggling to pay their bills.

Are we going to make that jump to say we have the potential of adding these services, but your premiums could jump up to as much as $8.22? We don't know the final jump of that. But again, like I mentioned in my opening, the trade off is immense.

You should have, if you didn't in previous times when it was just bills related to hearing aids. The long line of parents who are struggling to pay for these hearing aids just. Just breaks your heart.

Or individuals that came in and shared their personal stories about their process and journey on infertility and how they couldn't obtain their services. In the analysis, you'll see previous years spanning 10 years of attempts by different Members to include these benefits and failing each time.

And I think this is our best opportunity to jump on right now the current process that is in place for us to add to our essential health benefits. But I'm not naive to the situation of what can happen at the end of December. Obviously, I don't want that to happen.

In a perfect world, those subsidies will stay in place and we'll be able to add that it is going to take some time in those two years, if the subsidies go away. The legislature would have two years to come up with a plan before this goes into play. Because this is in 2027.

And I would hope that if the subsidies go away in those two years, we can make some investments. But of course, I don't know what's going to happen in the future.

But I think it's our best bet right now to submit this and continue the conversation as far as we can get it to get this across the finish line. And with that, asking for your support to ensure that millions of Californians can have access to life saving services.

Thank you, Senator. We will. Now did I see Senator Blakespear? Yes. Excellent. Hand the gavel back to the chair as we move to file item number two.

Senator, thank you. Here we go. Okay, thank you, Chair. Very simple topic.

True. I accept the committee amendments which will minimize disruptions to the Medigap market. Also, I'm committed to working with stakeholders to get this right for current and future enrollees. I am pleased to author SB 242, which is sponsored by a coalition of advocates for health care access.

SB 242 will improve healthcare cost stability and access to care for seniors and people under 65 with end stage renal disease. Did you know that seniors can be denied health care coverage due to pre existing medical conditions?

That's really shocking considering that that was prohibited in the insurance marketplace for adults under age 65 under the Affordable Care Act, which was passed by Congress in 2010.

But Medigap, an important supplemental insurance plan for Medicare recipients, can deny coverage or charge more for it for seniors with high blood pressure, chronic pain, asthma or any number of other medical conditions. In addition, what is also grossly unfair is while Medigap covers people under age 65 with expensive chronic health conditions such as Parkinson's disease or ALS.

It does not cover people with end stage renal disease. Thankfully, the state has the authority to regulate the terms of Medigap plans and so we can correct this. So SB 242 will require insurers during an annual open enrollment period at the start of the year to offer Medigap policies to seniors without penalizing them for their pre existing conditions.

And it will provide those with end stage renal disease access to Medigap. The urgent need for this became clear in fall of 2023.

That's when Scripps Health Medical Group, which is one of three major health care providers in my home County of San Diego, announced that it would not renew its contracts with Medicare Advantage plans due to years long delays in reimbursements.

That meant that seniors covered under Medicare Advantage had to move to a different type of Medicare insurance to keep access to their providers and many found out that they couldn't get on a Medigap plan to do that. Unfortunately, this is a growing problem.

16% of providers across the nation report that they plan to drop their contracts with Medicare Advantage plans in the next two years. SB 242 will provide seniors with an option to switch onto Medigap for free from fear of being denied coverage due to underlying health conditions.

Additionally, SB 242 requires Medigap insurers to sell policies to end stage renal disease patients so that they can get the life saving treatment they need to cure their illness and get back to living their lives. As it is today,

end stage renal disease patients without insurance covers- coverage only have one option and that is to reduce their income to qualify for Medi Cal Coverage in order to get a kidney transplant.

Giving people afflicted with end stage renal disease access to Medigap will be better for people with this condition and better for the state as it will save California approximately $15 million in Medi Cal costs. To conclude, SB 242 will do two things.

It will improve cost stability and access to healthcare for seniors and it will give end stage renal disease patients access to the cure to their condition. And with me to testiva- testify in support, I have Adam Zarrin, Regional Director of State Government Affairs for the Leukemia and Lymphoma Society. And I have Laurie Adami, cancer veteran and patient advocate.

Thank you for coming. You have a total of 5 minutes.

Chair, members of the committee My name is Adam Zarrin. I'm the Director of State Goverment Affairs for the Leukemia and Lymphoma Society. Our mission is to cure blood cancer and improve the quality of life for patients and their families. We are a supporter and co sponsor of SB 242.

That is because of the stories we hear from our patients like Laurie, whom you'll hear from shortly, and caregivers like Henry. Henry's wife is a blood cancer survivor. At 65 and relatively healthy, he joined Medicare Advantage because it fit his needs. Or so he thought.

But a few years later he had pain in his hand and needed surgery. The week of his surgery, his surgeon told him they were no longer in network. In an effort to remain in his surgeon's care, Henry tried to switch to a Medigap plan during an open enrollment but was denied because he has high blood pressure.

Henry was stuck with Medicare Advantage, but luckily his hand condition wasn't life threatening. But what if he needed chemotherapy or to see some other specialist? These are some of the denials and delays that those on Medicare Advantage often experience.

Denials of treatment and delays due to provider shortages or other snags can be detrimental to your health because of a choice you made during a one time only six month enrollment window at age 65. That's just not right. Many people over 65 have or will have a pre existing condition.

Does that mean that Medigap insurers can deny them all? Henry is one of many that CHABURP identified who are relatively healthy and want to switch to Medigap because they're frustrated with Medicare Advantages failure to provide timely care, but they're denied access entirely as Henry was or priced out of Medigap.

Why would we deny those on Medicare the same right that we all enjoy by law for the first 65 years of our life? That's just unfair and wrong again. So please consider what this bill is truly about. Giving Californians the agency they need to access adequate and affordable health care.

For these reasons, please support SB 244- 242 and vote yes. Thank you.

Chair and members of the committee. My name is Laurie Adami and I live in Los Angeles. 19 years ago I was diagnosed with follicular lymphoma, a type of blood cancer that can't be cured and requires ongoing treatment. Since my diagnosis, I have received seven lines of treatment including three clinical trials.

The seventh treatment I received was CAR T in trial in 2018, which for the first time put my cancer in complete remission. While I am thankfully cancer free today, I require monthly infusions to suppor- to support my immune system. After a dozen years of cancer therapy, I'm alive today because of my Medigap coverage.

When I left my work due to my cancer, I was put on original Medicare plus a supplemental Medigap plan, through my work disability plan. Medicare has billed more than 10,000 a month for each of my monthly infusions. Without Medigap, I would have to pay 20% of the cost out of pocket, and I simply couldn't.

This is what Medigap is for. To cover the cost that Medicare doesn't. Not just for cancer, but for any health issue. And this isn't just my story. Many people across California face the same challenges.

Without full coverage, they can't get the care they need, like a kidney transplant, a bone marrow transplant, CAR T or even a hip replacement. Doctors and hospitals often won't move forward with the care unless a patient can show they can pay the out of pocket costs. Dealing with the after effects of cancer continues for me.

My recent hip replacement surgery cost nearly $40,000, all of which was covered thanks to original Medicare and my Medigap plan. Most Californians can't afford a surprise medical bill over $500. That just seems wrong to me. If I hadn't had Medigap, I don't know what kind of sacrifices my husband and I would have had to make.

I've heard from other cancer patients who skipped treatments or went into debt just to stay alive. These are challenges I've never faced while on Medigap. Everyone deserves the same chance. SB 242 is essential. It ensures people can get the coverage they need without being turned away. No one should have to choose between their health and financial security.

Please support SB 242. Thank you.

Thank you so much for your testimony.

Any MeToo's in support? Name, organization and your stance, please.

Omar Altamimi on behalf of the California Pan Ethnic Health Network, in support.

Thea Zajac on behalf of the Leukemia and Lymphoma Society and also California Health Advocates in support. Thank you.

Sarah Nocito on behalf of the ALS Association which is proud co sponsor and the California Chronic Care Coalition, in support.

Christine Smith, Health Access California, in support.

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

Jonathan Clay on behalf of Scripps Health, in support.

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

Angela Hill on behalf of the California Medical Association, in support.

Jordan Gershman on behalf of DaVita. Supportive of the bill in print but still remove- reviewing the amendments. Thank you.

Good morning. Scott Sadler on behalf of the American Kidney Fund. We are in support of the bill in print. We also haven't seen the amendments yet, but we'll work with the author.

Pamela Zielski, on behalf of Dialysis Patient Citizens. We're in support of the bill in print, but still reviewing amendments.

Christie Foy, on behalf of the California Kidney Care Alliance. We're support of the bill in print and reviewing the amendments that just came out. Thank you.

Hi. Maria Garcia with Fresenius Medical Care, also supportive of the bill in print, reviewing the amendments. Thank you.

Jim Lindburg, Friends Committee on Legislation of California, in support.

Alejandro Solis on behalf of Los Amigos de la Comunidad, La cope de Cocina California, Central Valley- Central Valley Opportunity Center and California Human Development, all in support. Thank you.

Good afternoon. Shane Gusman, on behalf of Unite Here and the Machinist Union in support.

Formal opposition, please step forward.

Madam Chair and members, Stephanie Watkins, on behalf of the Association of California Life and Health Insurance Companies, Regrettably here today in opposition to SB 242. First, I'd like to thank the author and sponsor. We've had a lot of, you know, collaborative conversations.

Unfortunately, we remain really concerned with the potential devastating impacts this bill would have, not only on the viability of Medicare supplemental market, but more importantly on the 1.1 million seniors who by no fault of their own would experience significant rate increases if this bill were to pass today.

As many of you know, Medigap insurance helps protect people who are eligible for Medicare from high out of pocket costs not covered by traditional Medicare. Medigap coverage allows seniors, many of whom are on fixed incomes, to budget for medical costs and avoid the confusion and inconvenience of handling complex medical bills.

Currently, all Medicare supplemental policies are sold on a guaranteed renewable basis. This means that insurers cannot cancel the policy or change the benefits. This is a key element to understand as it underscores the stability and predictability of the current market.

For example, in California's current market, one is generally eligible to purchase any Medicare supplemental policy offered in the state during the initial six month open enrollment period. During the Medicare open enrollment period, the enrollees have guaranteed issue and cannot be charged higher premiums based on the health status.

This limited open enrollment period ensures that the risk pool includes a mix of healthy individuals and those with higher health needs. If an enrollee later decides to change to Medicare supplemental policy outside of the initial open enrollment period, California offers what we refer to as the birthday rule.

This allows 60 days opportunity commencing on the individual's birthday to switch to another Medigap plan if they so choose. California also has protections in place that allow enrollees and insurers to move from Medicare Advantage plan to Met SUPP plan if they experience a reduction in any of their benefits or an increase in their cost sharing or premiums.

While these provisions allow Medicare Advantage and Medigap policyholders a great deal of flexibility in their coverage options, it does include safeguards that help protect the existing risk pool. As many of you know, this matters because the fundamental principle of insurance involves the pooling of risk and ensuring that it's affordable for everyone.

To that point, according to the CHIPRP analysis, the average monthly premiums for Met SUPP will increase by $40 per member per month because of the average new enrollees in Medicare SUPP will likely use more services than the average enrollee at baseline.

Further, as noted at chaburb, the new entrance into the Medicare SUPP market will not only be higher costs, but they will likely displace lower cost enrollees who will find it advantageous to disenroll from Medicare SUPP rather than pay higher premiums.

I think in one of the examples they speak to a 67 year old who would almost receive a 98% increase in what their current premiums are. This would take them from based on to births analysis $160 per member per month to $317 per member per month.

That's certainly a huge issue and concern for us as you see the healthy young 65 year old's leaving the market are opting for Medicare Advantage versus Med SUPP and we additionally lastly are concerned about consolidation in the market and that we will have members who do close blocks of business and leave the marketplace.

And we see that as a huge concern because it does limit choice. For those reasons we are opposed, but look forward to having future conversations if the bill moves forward today. Thank you.

Good afternoon, Chair and members. Faith Borges on behalf of California Agents and Health Insurance Professionals, my members have the privilege of helping hundreds of thousands of Californians, especially seniors, navigating their health care options. And I want to begin by saying that we deeply respect the intention behind SB 242.

Protecting vulnerable seniors and ensuring access to supplemental coverage is a goal that we wholeheartedly share. However, we respectfully oppose this bill not because we disagree with its purpose, but because we're deeply concerned about the unintended consequences it could have on the very people that it aims to help.

Medigap policies are a lifeline for many seniors, as you've heard, but the premiums are already a significant financial burden for many. This bill creates a predicament of winners and losers.

As noted in the chiBIRP analysis, over 90,000 enrollees at baseline would disenroll from coverage post mandate due to increases in premiums, whereas 84,000 new enrollees would enroll in Medicare supplements post mandate. By removing underwriting entirely and requiring guaranteed issue each year.

For those who choose- who chose not to get coverage when they turned 65 and had guaranteed issue, this bill would declare them the winners at the expense of those who already enrolled and are managing their health care carefully.

When risk pools change dramatically, particularly if people wait to enroll until they need care, the subs- the sustainability of those plans is threatened and we've seen the impacts in other states that have enacted these policies. Coverage is hundreds of dollars more per month and there are few carriers left offering coverage.

Agents see firsthand how even a moderate premium increase can force a senior living on a fixed to make heartbreaking choices. And for those reasons, we would urge your opposition today.

Thank you. MeToo's in opposition?

Madam Chair, members, John Winger, on behalf of America's Health Insurance Plans, would align our comments with ACLID.

Thank you.

Sherry McHugh representing the National Association of Insurance and Financial Advisors in respectful opposition- opposition to the bill. Thank you.

Thank you so much. Bringing it back. And I'll- I'll kick off here. Vice Chair, if you don't mind. I get the intent, Senator.

And as you'll see in the analysis at the end, in the policy comment the committee wrote about how it's a lot, it's a lot in this bill, but we don't want seniors and people with disabilities to be trapped into their coverage. We don't want that.

And with the proposed with the amendments that the author is taking, we're moving away from the community rating and we're going to delay the effective date and tie rates to age bands so that people with disabilities can be charged no more than two times someone in the 65 to 69, no more than 1.25 for the people that are in the 70-79 age group and no more than 1.5 times when you're 80 and above.

There's a lot more work that needs to be done in this bill and we've had this conversation conversation with it and we were trying to get at just there wasn't enough time to get at everything.

And the- You know, we're moving this bill out with the intention and that the author knows that she will continue to work with stakeholders and the policy committees on this co- on this committee to still address some of the issues. One of the biggest concerns were the $40- $40 a month per member per month that Shapurb put in their report.

Additionally, the impacts that it would have on the current enrollees. And that's what we were trying to get at with the amendments, a lot of concern in ensuring that we're protecting the people that are signed in right now and that it's not their fault. Right. And we didn't want that.

We didn't want them to have or experience a rate shock as the market transitions and some may have to choose to disenroll. So the concerns from the opposition are real concerns that I would hope we can continue working. But I do thank you.

Thank you for working with my team and trying to mitigate some of the impacts in the existing Medicare supplement enrollees.

Yes. Thank you, Madam Chair. So I do have some serious concerns about the unintended consequences here, specifically adverse selection and higher risk. Less healthy individuals are more likely to enroll while healthier people stay out of it.

And if insurers are forced to charge average premiums but only high risk consumers enroll, then they face losses from higher than expected claims and this leads to premium increases over time. Insurers may respond by closing their books, as was- as was mentioned. And we've seen this happen in the California homeowners insurance insurance market. Right.

And that poses some serious, from my perspective, threat and risk here. And the California Health Benefits Review Program estimates that this bill could result in a 9% drop in Medigap enrollment with cost increasing as the- as the pool gets sicker.

So given how the health plans see this playing out, what policy changes, if any, do you think you would- you have or could suggest to mitigate the risk of market destabilization here?

Yeah, yeah, I think that's, that's a conversation we've had a lot. I think last year we really dug into their current existing protections that I- the agents and brokers are really familiar with and are able to move people from the- from Medicare Advantage to Medigap if they have any reductions and services are lost.

And so what we were trying to target is we think there's- there's current existing protections and assistance that would really help those individuals move. And we wanted to have those kind of conversations of as a part of that more targeted approach, are there specific additional things that could be added to those existing protections versus upending?

And really, I mean as it sort of stated, there's a lot this bill does from community rated and even moving towards age bands. I mean those would- we have significant concerns about what that impact would be to consumers and people able to pay those premiums.

And as you mentioned, I mean, I think this last year with wildfires, we've learned that California is not too large to fail. We will have insurers who leave the market. That's what we've seen in other states.

The big insurers will likely stay, but for many of my life, folks who have smaller books of business, those will be the ones that consolidate. Less choice is not good for anyone. And so that's- that's sort of a balanced concern.

But I think from our perspective, we'd really like to look at and build off of what Jackie Speier did many decades ago and Senator Monning did as well.

That really spoke to when there is an experience for Medicare Advantage individual where they have an increase in premiums or lose providers allowing them assistance to move into a Met Supp. So a much more targeted sort of answer versus what this does is sort of really rewrites guaranteed issue in the Met Supp market.

Well, I do hope that- Did you have?

Oh, yeah.

Okay. Senator Weber Pierson, you're recognized.

Oh, sorry, I thought you.

No. Okay.

Are you done with your comments?

Yes, it's okay.

Okay. Really want to thank the Senator for bringing this bill forward. Okay. Really want to thank the Senator for bringing this Bill forward.

You know, one of the things that struck me about this bill and I'm glad that with the amendments they're working on some of the issues with the affordability, but one of the things that really struck me with this bill was the initial basic statement that, you know, this includes people who are 64 years of age or younger who do not have end stage renal disease.

And I thought that was so interesting out of all of the different medical conditions that someone would single out end stage renal disease. And when you look even deeper at that, blacks have end stage renal disease four times more than whites, Hispanics and Native Americans two times more.

So this in itself is so discriminatory based on not only medical conditions but actually one's race. And so I am very happy that we are removing this from- from our statute and really appreciate the fact that with the amendments that that is still in there.

Because what we should be doing going forward is taking a lot of the bias and discrimination out of our health care settings because that is why we see so many disparities in healthcare outcomes. That's why we see so many disparities in life expectancies. And so I was actually quite offended that this was in, but very.

I really want to appreciate you for taking this on and taking that out.

Senator Richardson.

Thank you, Madam Chair. First of all, I want to join in the comments of my colleague of applauding the author for taking on this very important issue. Some bills are a little easier than others. This one certainly was not easy. Anytime when you're dealing with healthcare and coverage. My father suffrated- suffered from renal disease. I had diabetes.

Many of the things that were discussed by my colleague from San Diego. And to imagine that we would have a gap that would prohibit people from receiving care is just not right. So I commend your efforts. Thank you. Those for who have come to testify and when the appropriate time.

I realize we may not have a quorum at this moment, but when we do, I'd like to move the motion. Thank you very much.

And so I'll just add that I- I don't disagree that anything that either Senator Richardson or Senator Weber Pierson said that is probably a really positive part or provision of your bill. However, I do come back to I have serious concerns of not wanting to see what's happened in California's insurance market happen with Medigap coverage.

And so with that, you're welcome to close.

Okay, thank you. Well, I really appreciate the comments from all the Senators who spoke, including the chair who stepped out. And I appreciate Senator Weber Pierson, you contextualizing that- that- that carve out because it struck me as well when I read it, of all the things that could be carved out, why this one?

And so I just appreciate the comments. I wanted to point to because there many of the letters in opposition and as it came up here today pointed to this idea that there would be adverse selection by incentivizing people to buy Medigap plans when they get sick and leave when they're healthy, basically.

And I think it's important to look back at the Trebirp analytic model which shows that while there is some adverse selection that's happening or that may happen is what it may happen that would be offset by people with average health care costs switching from Medicare Advantage due to their dissatisfaction with Medicare Advantage plans.

And that could be because of the limited network or the delays or the denials. There are all sorts of reasons that people are dissatisfied.

So I did- I do want to just recognize that the conclusion that premiums would increase an average of $40 a month per person, you know what that means is for that price of a dinner, we can make seniors stable and have access to the health care that they need as they age, which is a priority, I think, for all of us here in the State of California.

So with that, I respectfully ask for your aye vote.

Thank you, Senator. When we have a quorum, we will take up the bill.

Okay. Thank you so much.

So we're now going to be moving to file item number six, SB 588 by Senator Ochoa Bogh. Okay. And Senator Bogh you are welcome to begin when you're ready.

Okay. Madam Chair and Members, I'm pleased to present Senate Bill 588, which will direct the California Department of Healthcare Access and Information to conduct a comprehensive study on the feasibility—this is a study—on the feasibility of Freestanding Emergency Departments, or FEDs, in rural, disadvantaged, and underserved areas with limited access to emergency care.

In order to address emergency care deficiencies across the state, we must think outside the box and pursue creative solutions to issues that have gone unresolved for decades. The proposed HCAI study would strongly evaluate the health care needs, operational models, economic viability, regulatory barriers, and community impacts associated with the construction and operation of FEDs.

For the purposes of this Bill, an FED, or a FED, is a licensed facility that is structurally separate and distinct from a hospital, provides emergency care, and is structurally separate and distinct from a hospital; is available to the public 24 hours per day, seven days a week, and 365 days per year; is staffed by appropriately qualified emergency physicians; has adequate medical and nursing personnel qualified in emergency services and care, and would be required by an emergency medical services permit and any services that would be specified on a services inventory report; has a policy, agreement, and procedures in place to provide effective and efficient transfer to a higher level of care, as required; receives the same level of reimbursement from all payers for both the physician and technical component fee as a traditional hospital-based emergency department; and is licensed by the State Department of Public Health.

With that in mind, FEDs differ from urgent care facilities in their ability to provide a wider scope of services, higher levels of care for emergency needs, and more advanced procedures on site. For patients that arrive needing trauma care or hospitalization, the FED provides an opportunity to stabilize their condition and prepare them for transport.

Currently, California—California's remote communities suffer from a shortage of convenient and accessible healthcare providers, and residents often travel great distances for basic health care. Even with reliable transportation, this distance can be specifically or especially problematic when it comes to unexpected emergency situations.

No, sorry, no, I'm just trying to catch up here. Give me one moment, please.

Okay, so per the American College of Emergency Physicians, an FED. Let's see. So with that in mind, FED's, as they are characterized in this Bill, are definitely not urgent care centers. For patients who arrive needing trauma care or hospitalization, the FED provides an opportunity to stabilize their condition and prepare them for transport.

California's remote communities suffer from a shortage of convenient and accessible health care providers. And residents often travel great distances for basic health care. Even with the reliable transportation, this distance can be especially problematic when it comes to unexpected emergency situations.

For example, the eastern Coachella Valley just outside my district not only suffers from a shortage of preventative health care options, but also lacks a centrally located 24 hour emergency Department.

The closest emergency Department are located at John F. Kennedy Memorial Hospital in Indio and Pioneers Memorial Hospital in Brawley, forcing thousands of residents to drive up to 45 minutes to access emergency care. But distance is not the only issue. Many emergency rooms across the state simply do not have the capacity to meet the intense demand for services.

For example, the Emergency Department at JFK Memorial Hospital saw over 42,000 patients in 2021, spread across 12 treatment stations, averaging over 3,500 patients per bed. That same year, the emergency Department at Pioneers Memorial hospital saw nearly 37,000 patients across their 16 treatment stations, averaging nearly 2,000 patients per bed. The numbers speak for themselves.

These ratios far surpass the statewide median number of emergency departments visits per treatment station in 2021, which was 1270. This issue is not unique to the rural areas. Even those of us who live in more urban areas and have reliable hospital near home have experienced long wait and overcrowding at our local emergency rooms. I speak from experience.

When my son suffered a severe mountain biking accident and broke his arm in multiple places. We sat in the in the waiting room for at least four hours, experiencing severe agonizing pain with no relief in sight because a Doctor had not been assigned to get just basic, basic pain medication.

My husband also that same year was hospitalized or took him to the ER. Well, actually I took him to urgent care first for a kidney stone, which we learned later was a kidney stone to urgent care.

They couldn't take care of him, so we went to the local ER. Took him several hours before he was also able to receive basic pain medication. I want to emphasize that we need to invest in all levels of care in all communities.

I think everyone in this room can agree that preventative care is the best way to decrease the likelihood of any emergency event. But it's time to face the reality in front of us. Access to preventative care is not expanding fast enough to meet the demand.

And while we work on those long term solutions, California deserve an emergency lifeline in the moment when it matters the most. I've always been a firm believer in making sure that all voices are heard and that everyone has a seat at the table when it comes to working on policy.

SB 588 seeks to set the table for those conversations by engaging with stakeholders for a comprehensive study of the feasibility of freestanding emergency departments. I welcome all proponents and opponents to provide insight on how their industries, expertise and skills can help fill this important gap in healthcare.

Joining me today is Dr. Andrew Kassinove, medical Director of the Emergency Department at JFK Memorial Hospital in Indio, and Dr. Karin Freese, Chief Executive Officer of Del Puerto Healthcare District. We're happy to answer any questions you may have about FED's.

Good afternoon Senators. Thank you for being here and for allowing us to speak to you today. I'm here today to express strong support for Senate Bill 588 which authorizes a feasibility study on establishing freestanding emergency departments in rural and underserved communities.

As the CEO of a small healthcare district based in Patterson and a committed advocate for equitable access to care, I believe this study is a critical step toward addressing urgent gaps in our urgent response system. Located in western Stanislaus County, Patterson has been served by the Del Puerto Health Care District since 1946.

We operated the community's acute care hospital while declining inpatient demand forces closure. Today we operate a federally certified rural health clinic and provide 24 hour emergency ambulance services. Despite these efforts, our community still faces serious challenges in accessing timely emergency care.

The nearest hospitals are in Modesto and Turlock, each more than 18 miles away, requiring at least a 25 minute drive on rural roads. Tragically, this delay can be the difference between life and death. On October 8, 2021, seventeen year old Jose Mendoza was stabbed during an altercation in Patterson.

His mother was faced with an impossible choice wait for an ambulance to arrive or attempt to drive him herself to the nearest emergency department. In that moment of panic and urgency, she chose to drive. But at mile 14 of their 18 mile journey, Jose succumbed to his injuries, bleeding out before he could receive the emergency care.

Had he reached advanced life support sooner, he might still be alive today. This heartbreaking loss illustrates the painful and unjust reality that so many rural families face. SB 588 provides a thoughtful life saving opportunity by studying the feasibility of freestanding emergency departments that could provide 24/7 care independent of hospitals.

Today you may hear testimony that draws conclusions on freestanding emergency Department feasibility. However, this Bill simply asks for a study to evaluate possibilities. I urge you to support SB 588 and allow the study to go forward. Thank you.

Thank you Members of the Committee, Madam Chair and Senator, I'm Dr. Andrew Kassinove. I'm a board certified emergency physician and I've practiced in California for over 25 years. I practice mostly in underserved communities throughout my career and currently for the last 11 years have been the Medical Director at John F. Kennedy Memorial Hospital in Indio.

We care for a mixed population with including a substantial amount that are underserved. The Senator pointed out earlier that our volume, it's actually much worse than she pointed out because it's gotten much worse over the last several years. Now, in 2024, we saw over 50,000 patients in our small licensed 12 bed emergency Department.

So we're facing an overcrowding issue in emergency departments throughout the country. But specifically in areas that border underserved areas or in underserved areas. This study would look at the feasibility of freestanding ED's to help with that crisis. And freestanding emergency departments provide another access point for care for our California patients. And that care is really needed.

As everyone has pointed out, people wait a long time in emergency departments. And if we can provide more emergency departments throughout the, the, in underserved areas, we can provide that care and provide that access to care and reduce wait times and provide better care. I understand that there's some concerns that it might be just an urgent care.

Well, the main difference between an urgent care and a freestanding emergency department is that a freestanding emergency department is a true emergency department. It has a CAT scan, it has a lab, it has the ability, it has emergency physicians trained to provide emergency care working there.

And if you go to a freestanding emergency department, you don't then get sent to an emergency department from there. If you need to be admitted, you get admitted directly to the affiliated hospital and that's a huge time saver.

And that duplicates that emergency department as another access point throughout an underserved community, reducing wait times and providing care to that community. So I strongly urge you all to support this study to determine if this is a good policy move for our patients in California to give them this other opportunity to access care. Thank you.

Thank you. I'll now turn to any me too's in support of this Bill.

Good afternoon, I'm Roxanne Gould representing the American Nurses Association of California, in support.

Thank you, Madam Chair and Members, Sarah Bridge on behalf of the Association of California Healthcare Districts, in support.

Good afternoon, Madam Chair. I'm Saurabh Kumar. I'm Medical Director, Program Director of Desert Care Health District and Desert Regional Medical Center in support of Bill and co sponsor.

Thank you so much. We'll move to formal opposition. Please come on up, gentlemen. You have a total of five minutes. Whenever you're ready.

Good afternoon. Matt Lege here on behalf of SEIU California, appreciate the opportunity to speak. First, I just want to appreciate the goals of the Senator's Bill. You know, really appreciate the desire to try to expand access to care. I think we share in that desire.

Unfortunately, from our view, we don't think Freestanding ERs are the way to achieve that goal. I also want to thank the chair and Committee and the staff analysis that lays out the long history of concerns around freestanding ERs. This isn't a new issue in California.

It's something that's been discussed quite a bit and so, you know, want to highlight some of those concerns. Also, something presently particularly troublematic is half of Californians are delaying access to care because it costs.

And so that's really one of our primary concerns with freestanding ERs is what we've seen in other states, particularly Texas and others, is that because patients that are, instead of getting primary care, going to our urgent care facility, end up going to one of these freestanding ERs to get what would be comparable care at the urgent care facilities at what one study showed, more than 10 times the cost.

Unfortunately, patients, particularly in an emergency, as talked about earlier, or in a desire to get care immediately, are often confused by whether or not it's a freestanding ER or urgent care facility. And then patients, when they do choose wrong, when they could get care at an urgent care facility, are stuck with those high out of pocket costs.

And then that of course add cost to the larger system. So something that I think everyone is trying to grapple with. Additionally, as pointed out in the analysis, freestanding ERs are not subject to EMTALA, the federal law requiring that we serve everyone regardless of their ability to pay.

And so this Bill will actually cause the ability for freestanding ERs to turn away patients. So you're either faced with having the wrong insurance or even potentially bleeding out in the parking lot, which is incredibly problematic.

With regard to the study, we do feel that the study does not include the voice of healthcare workers in the study currently. It also predisposes some of the outcomes of the study, including requiring that same level of reimbursement as other emergency rooms.

As mentioned the cost is an incredible concern and you're sort of predisposing the outcome of that study. Nurses and frontline healthcare workers rely on these support services that are often not included in freestanding ERs to care for our patients, including radiology, surgical and intensive care.

And without those services, patients will need to be transferred to get some of those basic levels of care. Additionally, the study fails to discuss or highlight the need for appropriate staffing, affirm the risks nurse to patient ratios which apply in California and how that would work with freestanding ERs.

While we share in this goal of expanding access to care, we do not think SB 588 does that by, and creates additional inefficiencies in our healthcare system and inequities associated with freestanding ERs, further fragmenting the care model in California. For those reasons, we are respectfully opposed to the model.

Thank you Madam Chair Members. Tim Madden representing the California chapter of the American College of Emergency Physicians and our folks who are opposed to SB 588. California ACEP has actually looked at this model for years and they've talked about it and debated it and they have a few primary concerns as it relates to the freestanding emergency Department model.

The concerns are centered on the freestanding emergency Department being built near an existing community hospital. And what we've seen is that results in the highest paying patients are being siphoned or diverted away from the community hospital to that freestanding emergency department.

And for many of our community hospitals and underserved areas, they're very reliant on those higher paying patients. As they may have a population that's upwards of 80% Medi Cal and underinsured, uninsured population.

So if you siphon away even 5% of that population, you're putting significant strains on that community hospital, which may put them in even a tougher financial situation than they're currently at today.

We understand that SB 588 is looking to study the issue, but as the analysis details this, this freestanding emergency department model has been around for years and as just previously mentioned, has been utilized in a number of different states. So we think there's more enough data out there to support our concerns around this model.

And at this point we just don't feel a study is needed to look at this any further. For those reasons, we're opposed.

Thank you so much. Me too's in opposition.

Carmen Comsti, with the California Nurses Association, in respect—respectful opposition.

Thank you so much. Bringing it back. Colleagues, I'm going to kick off this conversation here. You know, the author and I spent some time talking about this last night. So, I say I don't want to belabor the argument, I might.

I want to start with some questions because, you know, we've been having a lot of conversations about what is bogging down our ER system.

And this Committee has approved, has voted on bills, to help address that with paramedicine teams, treatment medicine team, to divert patients away from the ER, that should be seen in a primary care or urgent care. So, Doctor, you talked about your ER and the crowdedness.

Can you tell me what you think is driving the crowdedness in your ER?

Well, I would say I'm sure that patients don't always know where to go. They don't always have primary care. So, regardless of whether or not it's a freestanding ER or a mainstream ER, we see patients who could be seen in their primary care office or could be seen in an urgent care. That's just the fact of life.

The 50,000 patients that I see—that we see—every year in my emergency Department, there is certainly a percentage of those that could be taken care of in an urgent care setting and in a primary care setting. But that's, that's a problem we have in California right now. So, I.

So, why wouldn't we invest more in primary care?

Well, we should, but we have—we still have an Emergency Department issue. Patients are still coming to the Emergency Department. We need to provide care in underserved areas, emergency care in underserved areas, because those patients have to travel really far to get care.

So, if they have to travel 40-50 miles to get care and they can—we can—meet them halfway with a staffed Emergency Department that could stabilize them, that could treat them, that would be a huge boon to the health care of those areas.

I—your support letter talked about one of the things you're looking to achieve is to decrease transports to main hospitals. And I'm not a doctor. In my short little five years that I was an EMT, I worked as an ER Tech. And in my handful of stories, I dealt with patients.

There's one in particular that I remember, an individual who had crush injuries, pneumothorax. It was really, really bad. We were able to stabilize him. Okay? I was part of that team that stabilized him. On the way to the second floor, he died. You're asking for freestanding emergency. That's gonna—you're asking for them to stabilize.

And then what happens? There's nothing attached to the freestanding emergency room. You're looking to then wait for them to be transferred to a hospital.

So, it's the same thing that happens right now, honestly. So, in my Emergency Department, where I work at, we are a lower level, a level four trauma center. If we get a trauma that comes in or EMS calls us with a trauma that's severe, they may ask us to stabilize for, for 20 minutes.

They may ask us to intubate, to do something to stabilize them, and then, they will wait and take them to the trauma center. So, a freestanding ER could do exactly that as well, locally—they could intubate, they could stabilize them.

Those are for transfers. You're going to have people that are going to be driving to your freestanding yard with GSWs, with TBIs, and it's going to be very—it's hard for me to believe that they're going to be able to be stabilized and still travel the 14, 18 miles that's to another hospital.

It's the same thing, honestly, as any small Emergency Department. Any small Emergency Department can't handle a major trauma. All they're going to do is stabilize and transfer to a, to a major trauma center. So, there's really no difference. They're not going to go to the operating room in a small hospital.

They're not going to go to the intensive care unit in a small hospital. They're going to get transferred to a major trauma center.

So, having the emergency capabilities, having a trained emergency physician closer to these underserved areas, to do something in the meantime, even if it's for 10 minutes, 15 minutes, to stabilize them, to help them before they get transferred, or someone shows up and can get stabilized while EMS comes, because they got dropped off, that's a huge help to these patients.

And it's no different than what we have—the system we have now.

I would disagree. It's completely different. These aren't attached to acute hospitals. And there is going to be confusions—confusion—of consumers looking to say this is an Emergency Department, they're going to go to it, and it's not. I keep calling them glorified Urgent Cares, but you're just going to—people are just going to pay more because it's Emergency Department where you can get the same services—some of the same services out in Urgent Care.

I mean, you can get some of the same services in Urgent Care as you get in a regular Emergency Department as well, so.

Right. And we want to divert those people away from the Emergency Rooms into Urgent Cares.

Absolutely. But I think what we're looking to do is provide the emergency level care for these communities. Now, that comes with providing some urgent level care because patients do get confused. To your point, higher level of care, patients will maybe not get confused but look at that as the first access point.

The same thing happens in the rural hospitals. If you have a GSW and you walk into a rural hospital, they can't treat you there, other than what they can do in the Emergency Department.

So, having a duplicated Emergency Department access point out in the community that can do what a rural hospital Emergency Department can do is what we're really asking to study. Because if you have the equivalent of a rural hospital Emergency Department out there providing that, that's the same thing that a rural hospital can do.

But you're giving that extra amount of care availability access point to patients.

Tim, I'd like to hear your thoughts on what the Doctor was mentioning around the stabilization and this will help—kind of like the cutoff man that you see in the outfield of a baseball field.

Yeah, and that's, it gets—I think we spent more time looking at it from an urban, underserved area, where, as I was mentioning, the freestanding Emergency Departments are getting located near an urban underserved area and they're kind of siphoning off those patients for what the emergency physician was talking about. I think we can see that value.

But I think, when looking at previous legislation around this in other states, is, are there enough of those cases to even support that type of a structure in that area? There was one occurrence, and it was in the analysis where they were looking at it, and it ended up not moving forward because the funding just wasn't there.

So, I think one of the questions is, is there the volume of a GSW or those heavy trauma cases that would benefit from that proximity, that will allow them to stay open?

And the concern then is, do other—going to the points that Mr. La Jay made—will people be confused going into that Emergency Department thinking they're receiving certain services that aren't available? And those are some of the challenges that we see with that type of a model.

We're striving the principle—and should be for anybody outside of this Committee Health—is that we should be striving for right care, right place, right time. And while we haven't done a study on this, we can turn to states like Texas and Colorado to see how they're running.

And what we see there is what we've heard from the opposition, that only certain amount of certain type of people go to these free-standing Emergency Rooms and it tips the balance of hospitals that are seeing 80% of Medi-Cal patients.

And the commercial payment—commercial plans or enrollees of commercial plans—go to one specific freestanding Emergency Room because they don't want to deal with the bogged down time, the long waits. Even in the Support Letter from your sponsors, Senator, it spoke to we want to reduce the wait times for people.

And for me, I want equitable access to health care. My goal is, yes, to reduce time, but for who? For everybody. Not for a certain amount, not for certain individuals. While I recognize this is just a study Bill, I can't vote on something that, on principle value, I don't believe in freestanding Emergency Rooms.

So, I can't support a study of something that, on principle, I don't believe that will help consumers, will address the gap in health access. I know the lack of access in rural communities is a real thing and we talk about that all the time, and I shared with you, Senator, about that.

I think we need to help provide access to primary care. I'm not convinced that we're going to have—I'm not convinced that people won't be confused about this. I'm not convinced that this is going to help address the route that you're trying to get at, Senator, which is why I'm recommending a "No" vote on your Bill.

I think patients who are facing a true emergency are not going to be able to be—this is not going to address them. And those who go to a freestanding Emergency Room are going to be shocked with the Bill that they're going to see when we could be rerouting them to an Urgent Care.

So, that is why I'm recommending a "No" on this Bill. I'll turn it to my colleagues for additional questions.

Thank you, Chair. Really want to thank the author for bringing forward this Bill and allowing for us to have this conversation. We have significant issues of access of care here in California and you know, we've got to fix it. I'm not sure if this Bill or this study would do it.

And I echo a lot of the concerns from our Chair. You know, there is something that you were trying to differentiate, which is that freestanding ERs are not Urgent Cares and they're not, but they're also not ERs.

When you look at an Emergency Room that is attached or affiliated with a hospital, you have more than just Emergency Room physicians there. You have radiologists, you have other specialists that you can come into and call down or do consult. I've had way too many ER consults in my lifetime, especially as a Resident.

But that is a part of providing care and the vast majority of patients that come through the ER are not your trauma patients. They are patients that need the services of other providers. When I was on faculty at UT Southwestern, we had our own ER for women, right.

And the vast majority of those people that came through were not there for trauma. They were there for primary care purposes. And so, I do think that having this freestanding ER would give a false sense of security for patients. It's already very confusing for patients at times.