Assembly Standing Committee on Health

Good afternoon and welcome to the Assembly Health Committee hearing on this day, Tuesday, July 8th of 2025. Before we begin, I want to make sure everyone understands our Committee procedures to ensure we maintain order and run a fair and efficient hearing with the goal of hearing as much from the public within the limits of our time.

We seek to protect the rights of all who participate in the legislative process so that we can have effective deliberation on the critical issues facing California.

Rules of conduct for Members of the public include no engaging in conduct that disrupts, disturbs or otherwise impedes the orderly conduct of this hearing Engaging in personal attacks of Members of this Committee, author, staff or other witnesses talking or loud noises from the audience.

Please be aware that violations of these rules may subject you to removal or other enforcement processes. If you are providing witness testimony at this hearing, all witnesses will be testifying in person. Main support and opposition will be allowed two main witnesses for a maximum of two minutes each.

As a reminder, primary witnesses in support must be those accompanying the author or who otherwise have registered a support position with the Committee and the primary witnesses for opposition must have their opposition registered with the Committee per the instructions on our website. All other support and opposition can be stated at the standing mic.

When called upon to simply state your name, affiliation and position. All testimony comments are limited to the Bill at hand. Some housekeeping items I would like to note that we have a couple of Members substituting today for for today's hearing, including Assemblymember Elhawary, substituting for Assemblymember Krell. Assemblymember Ellis. Welcome. Substituting for Assemblymember Patterson.

Assemblymember Rogers substituting for Assemblymember Carrillo. For today's hearing. On the consent agenda, the following bills are proposed for consent for today's hearing. We have Item 1, ACR 94 (Patel), motion is to be adopted.

Item number 5, SB 228 by Cervantes, with a motion of do pass to appropriations. And item number 8, SB 764 by Weber Pierson with a motion of do pass to Appropriations. Any Member of the Committee may remove a Bill from consent.

With that we will be able to start as a Subcommitee while we wait to establish quorum and while we wait to have an author.

We will. Start as a Subcommitee with item number 2, SB 27 by Umberg. Welcome, Senator. Senator, I think you might have to press that button.

I've only been here eight years. Thank you Madam Chair and Committee Members for your patience here. I'm quadruple tasking, probably just like you are right now, I'm here to present SB 27. Thank you very much for your assistance, Logan Hess. In particular, we're prepared to accept the Committee's amendments.

They include the removal of the expansion of CARE Court to mood disorders with psychosis, to bipolar 1 disorder with psychosis; clarifying the definition of clinically stabilized to match the original intent of CARE Court; and clarifying the role of nurse practitioners and physician assistants.

As I think some of you know, CARE Court was actually initiated by the Governor, and I was pleased, along with Senator Eggman, to carry the original legislation. This is the third iteration of CARE Court cleanup.

It is a process in the civil courts which addresses issues by those who are experiencing schizophrenia, schizophrenia like symptoms, and now also potentially expanding it in a relatively small way to those with bipolar one disorder with psychosis. The purpose of Care Court is to have one person hold the institutions as well as the individual accountable for progress.

Institutions being the county in terms of supplying transitional housing or housing, as well as behavioral health professionals, and also the individual have the individual report frequently for purposes of accountability to the court. That's the benefit of CARE Court, is that there is accountability.

Now with me here to Testify concerning the SB 27, the Revisions to CARE Court is Dr. Aaron Meyer, Behavioral health officer for the City of San Diego, and also Elizabeth Keanu Hopper, family Member whose daughter was enrolled in CARE Court. So thank you, Madam Chair.

Thank you so much. You'll each have two minutes. Please go ahead. Whenever you're ready.

Good afternoon, Chair Bonta, Members of the Committee, my name is Aaron Meyer. I'm a practicing psychiatrist and assistant clinical Professor at the University of California, San Diego. While I'm not speaking on behalf of the University of California, I'm here today as the City of San Diego's behavioral health officer, proud supporter of Senate Bill 27.

So the hope of the CARE act program was to prevent avoidable psychiatric hospitalizations, incarceration and conservatorships by offering a structured path to recovery and stability through a new civil court process. If implementation is going to match the hope of the CARE Act, we must address the high percentage of CARE Act petition dismissals.

DHCS recently reported that 62% of family petitions were dismissed. What are the reasons? The state bar affirmed that 19% of petition dismissals were related to the respondent's enrollment or likely enrollment in behavioral health treatment. An additional 7% were dismissed because the individual was already stabilized in ongoing voluntary treatment.

For respondents who were already enrolled in treatment prior to petition filing, why would people take the time and effort to Complete these petitions when everything is fine. When testifying last week before the Assembly Judiciary Committee, I mentioned an individual with a pending CARE petition. They haven't changed their clothes in over a year. They require prompting to eat.

They refuse to move to a more supported setting due to paranoia. I just learned that their CARE petition was dismissed because the patient is already enrolled in an ACT program. SB 27 may decrease these dismissal rates by clarifying that clinically stabilized and ongoing voluntary treatment means the person is managing symptoms through medication or other therapeutic interventions.

And it clarifies, and this is the most important part, enrollment and treatment alone may not be considered clinically stabilized in ongoing voluntary treatment. It must mean more so Senate Bill 27 creates clarity so individuals who require more support receive it. We must do better. And with your support we can.

Thank you. Go ahead. You'll have two minutes to make sure you press the button.

Thank you, Honorable Chair and Members, I really appreciate this opportunity to be here. I have a daughter who is currently in the beginning phase of being offered CARE Court services here in Sacramento area.

She qualified two days after my submission of the petition because she did meet the narrow criteria of age, location, diagnosis, duration, severity level and recent exit from incarceration for being incompetent to stand trial. She's currently living unhoused at Cesar Chavez park, didn't have an ability to work with reentry services to accept those services.

So thankfully I was able to do the CARE Court petition. The CARE Outreach team is already currently meeting with her at her unhoused spaces to build trust, offer services, different types of housing, and to engage her in tailor making a plan for her own success.

As she defines it, her participation is completely voluntary and even though it may take several meetings, the team is tasked with trying for many weeks to encourage participation. During this time, the petitioner, that's me in this case, is not allowed to exchange information with the CARE team and this is a safeguard against undue pressure and coercion.

Our path of support for our daughter, who's age 35, started 15 years ago. Through the years she received several different diagnoses, including depression, borderline personality disorder, bipolar disorder, and the longest lasting standing diagnosis of schizoaffective disorder.

Over time, every relapse that was not immediately treated took her longer to recover and repeated psychotic breaks compounded the difficulty in regaining her functional cognitive and motivational abilities.

I feel sad to sit here and report that we, her family, feel lucky to have the diagnosis of schizoaffective disorder so that she qualifies for the specialty intense and persistent services of CARE Court. Schizophrenia spectrum disorders are not the only ones that devastate some individuals.

I support SB 27 because it appropriately extends to other diagnoses with psychotic features and it maintains the rigorous boundaries of severity, duration and impairment. And it includes safeguards. My daughter tried every other level of care available and none of them have been enough care to live safely and contentedly in the community.

She had outpatient intensive, outpatient intensive community treatment, full service partnerships and eventually the felony incompetent to stand trial programs. CARE court. Now that she's released, CARE court is the next least restrictive restrictive option. Please support SB 27. Thank you.

Thank you so much. Now we'll hear from others in the hearing room who would like to offer support for the measure. Please state your name, organization and position on the Bill.

We also have Ms. Stephanie Welch, the Deputy Secretary of Behavioral Health at the California Health and Human Services Agency, and Mureed Rasool with Judicial Counsel here for technical support.

Thank you.

Hello, my name is Allison Monroe. I'm co-founder of Families Advocating for the Seriously Mentally ill. And I strongly support this Bill. And it sounds like I support the amendments too. Thank you.

Danny Offer with the National Alliance on Mental Illness, also known as NAMI California in support of the Bill.

Kelly Larue for the California Chamber of Commerce, in support.

Good afternoon. Jacob Brent with the California Retailers Association, in support.

Ethan Nagler on behalf of the City of Bakersfield, in support.

Thank you. Now we will get to hear from.

Madam, Chair Members. Amy Brown on behalf of the big city Mayor's coalition, in support.

Thank you. We'll now hear from any primary witnesses in opposition. Please come forward to the table here.

Good afternoon, Madam Chair and Members. Michelle Cabrera with the County Behavioral Health Directors of California. And we must respectfully oppose SB 27 as amended recently.

Taken together, these amendments are intended to have the effect of exponentially expanding the number of CARE Court petitions in short order as the Bill has an urgency clause and the provisions would take effect immediately. We very much appreciate the work of the Committee to narrow the Bill from mood disorders overall to bipolar I with psychotic features.

However, this still represents an eight fold increase in the eligible population to take effect immediately upon enactment. As discussed by the witnesses and support today, a precondition of the CARE plan is that a person is unwilling or unable to engage in voluntary services.

From the start of this policy discourse, counties have flagged several questions and concerns about the proposed policy.

First, will we be able to establish and maintain therapeutic alliance if the clients that we serve, view us as an arm of the court, serving them with court papers and working at the behest of the court to get them into services. Where will the housing be to address their housing needs.

Counties have continued to have clients interests at heart in implementing the act. They have noted that a positive impact of this policy has been that it allows more people in our communities to learn about our work, our services, and the state reimbursement for activities like outreach and engagement, which historically are not medi-Cal reimbursable.

These intensive outreach services have been highlighted as the secret sauce of CARE Court. In fact, the resources for outreach and housing are exactly the tools that we've been asking for in our ongoing efforts to help those most in need by expanding the eligible population exponentially overnight.

Without more staff resources and perhaps more importantly, the housing to satisfy the courts, we will fall short of delivering both for those who come to us voluntarily, but perhaps more importantly for those whose needs are more intensive.

And while it's true that to date care plans have not reached the estimates that we all imagined we would have, we are suffering from the same paradox that plagues programs like AOT. That is our most successful forms of engagement.

Getting people into voluntary services without involving courts or formal orders and respecting their privacy and dignity means that our biggest success stories can't be tallied and talked about. Counties have faithfully implemented Care court in all 58 counties and the vast majority of our success stories are those people who say yes at the first offer.

The state has updated its reporting requirements so future reports will attempt to quantify voluntary engagement and the Legislature and its foresight asks for state auditors.

Impact of the CARE Court program. We're extremely concerned that with the urgency clause we will not have time to get our services up to the scale necessary and the courts will not have a chance to update rules, train judicial officers, or work with us to budget, recruit and hire the staff needed to expand our workforce.

When people are brought in, we have a promise and we hope to meet that. Thank you.

Hello. My name is Dr. Lynn May Rivas. I am the Executive Director of CAMHPRO, the California Association of Mental Health Peer Run Organization. I'm here representing the interests and values of the mental health consumer community. I'm also a representative of that community as I myself have bipolar disorder 1 and at one time I experienced psychosis.

I belong to the specific population being discussed here today. Underlying the so called CARE and CARE Court is a coercive legal process that can end a conservatorship and Involuntary institutionalization if you don't cooperate. And the ultimate irony is that CARE court does not provide any supports for the individuals targeted. There is literally no care in care court.

Before you invest millions of dollars expanding the system, I ask you, where is the evidence? Does it really guide a person down the road of mental health recovery? I doubt it. Also, whose interests are you pursuing with this Bill? I can tell you that it is not ours.

These are not the services we want you to invest in. Rather, we want you to invest in community organizations run by peers that provide support, hope and community. None of the evidence supports involuntary measures. Rather, choice is a key component of recovery. When we are forced into care, we feel demeaned and traumatized and. And we lose trust.

The good news is that there are alternatives that are proven. We do have the data that they're effective. Peer support within a peer run organization works and there are multiple studies to prove it. Having bipolar I is no joke. To function and have a life that's fulfilling, we need to access multiple therapies and supports.

I need to access multiple therapies and supports to be able to be here in front of you today. But just because I'm bipolar should not mean that I have less rights. I submit to you that just like all of us, I should always, always have the right to choose. Thank you.

Thank you. We will now move forward with those in the hearing room that would like to state an opposed position to the measure. Please state your name, organization and position only.

Mayeron, on behalf of Cal Voices and Mental Health America of California, opposed.

Clifton Wilson, on behalf of the board of supervisors for the counties of Fresno and San Joaquin. Currently in respectful opposition, but we will. Be reviewing the amendments. Thank you.

Andi Liebenbaum, County of Los Angeles with an in between. We were previously supportive of prior June 17th amendments. We are now neutral on the Bill.

Molly Mallow, on behalf of the California Association of Public administrators, Public Guardians and Public Conservators, respectfully opposed.

May Delo on behalf of California Behavioral Health public. California Behavioral Health Planning Council, respectfully opposed.

Madam Chair and Members. Gregory Cramer, on behalf of Disability Rights California. We're in strong opposition.

Good afternoon. Linda Nguy with Western center on Law and Poverty in opposition.

Rainer Apostol on behalf of Drug Policy alliance, in opposition.

Thank you. Before we bring it back to the Committee, we're going to establish quorum.

[Roll Call]

We have quorum thanks so much. And now we will bring it back to the Committee for any comments or questions. Majority Leader.

Thank you very much for bringing the Bill forward. I remember the struggle when we tried to get this through and we did get through with Senator Eggman and yourself. And I always thought of it as a foundation. And then we build on that foundation each time we come in and try to work on policy.

So I'll be supporting your Bill today and I'd like to move the Bill.

Motion by Aguiar-Curry. Questions from Patel.

Thank you for bringing this Bill forward.

As a representative of San Diego county, one of the pilot areas that was looking at CARE courts, I have to say we've come a long way and while we do see that there's still capacity in the system, we didn't get as many people petitioning for the services through CARE courts as we could have.

I am concerned by the opposition's concerns that we don't have capacity in our system to do that. So can you express in a more finite way what that capacity issue is. Because we're not near capacity with the first rollout.

Thank you so much, Assemblymember Patel. Yes, I can speak to that. So originally, as conceived, CareCorps was intended to really focus on an unhoused population with significant mental health conditions who did not qualify for a higher, more restrictive level of conservatorship, for example. However, the policy itself did not bring with it housing resources.

There was a one time investment in behavioral health bridge housing. Counties have spent down that investment. So we are currently housing individuals both within CARE court and more importantly, perhaps outside of CARE court. With that behavioral health bridge housing investment, we do not have extra housing resources currently to withstand an eight fold increase in the eligible population.

Meaning if we try to bring people into care court on the promise that there will be housing for them, it's. We don't have anything new right now for them. In addition, because of the ramp up time, we had essentially two waves of implementation. There was an initial pilot phase and then it expanded to all 58 counties.

That gave counties the time to develop budgets, to hire and recruit staff and train them in order to meet the needs. And one of the things that I tried to, you know, sort of paint a picture around is that we are seeing more people as a result of CARE court. They're just not all getting care plans.

And so it does bring people into county behavioral health. And we're really thrilled about that side effect, I would say, of care court. Our folks have found value in having this other level of Care.

The urgency clause in this, however, is something that we don't understand because the courts view us as the entity primarily to be held accountable.

And we in no way would be able to turn on a dime, pivot so quickly, and respond to their very rightful, you know, expectation that we're going to be handling these individuals with the care and consideration that they deserve being brought before the court in a civil court process.

And to our city and to our author. Do you have a response to that.

So thank you, Assemblymember Patel. You've hit the nail on the head. San Diego, as well as most counties in the state, are not experiencing the kind of numbers that were anticipated. That's okay, though. I mean, this is a project that is growing and it is innovative and is dynamic and it is new.

And so that's why we have cleanup bills last year and this year. I actually would refer to Ms. Welch and Mureed Rasool in terms of capacity, but I take your point. We're not at near capacity. I disagree in terms of the numbers because there's sort of a filtering process.

So first, to be eligible for care court right now, you need to have schizophrenia or schizophrenia, like symptoms, very small population. We'll expand it fairly finitely to those with bipolar I with psychosis. So in addition to that, you also need to be a danger to yourself or to others.

So I think they can probably respond as to what that means in terms of population. I can only refer to my own county. Orange County, which has been doing well, has the capacity. In fact, we are seeing increase in petition, but we're not near the top yet.

Thank you for that response. Did you want to respond as well?

Is this on. Hi, good afternoon. Stephanie Welch, Deputy Secretary at the Health and Human Services Agency. A couple of points I'd like to mention. One, the counties have been doing a tremendous amount of work utilizing their behavioral health bridge housing dollars to house this population.

A condition of those funds was that they had to be used to prioritize people who qualified for care. And so we are seeing that and are excited for them to continue to be doing so. We also are making a significant shift in the next fiscal year.

So fiscal year starting July 1st, 2026 counties will be able to use some of their BHSA dollars to pay for housing supports. We envision individuals who meet the criteria for care as being really appropriately placed in what we call ACT level or assertive community, assertive assisted community treatment models.

That's the kind of wraparound care which includes housing supports. And we do believe that, these fit well together. Part of the vision of wanting to refresh and modernize the Mental Health Services act into the Behavioral Health Services act was to make sure that there was more capacity to serve people who have very chronic complex conditions.

Now I do want to clarify that is beginning next fiscal year. So July 1, 2026. Would be happy to talk more with the counties about their concerns about not having enough behavioral health bridge housing dollars for current fiscal year. It's not our understanding that all counties do not have any behavioral health bridge housing money left.

And the last thing that I would say, and it is an important point, care was conceived also frankly to prioritize county behavioral health resources for those individuals who have the most severe, chronic and challenging conditions, those who are at the risk of the most negative outcomes that come from not frankly getting to be first in line because they have those needs.

So individuals who have repeat hospitalizations, individuals who rely upon crisis services, individuals who maybe only get care in the emergency Department, these are individual who actually are getting services. They're just not getting services that are community based and wrapped around.

So we would really look forward to continuing to working with the counties to make sure that they have that capacity. Feel supported by the state because we do want them to be successful. Serving this population is incredibly challenging and we've seen tremendous success stories.

I hope the same for the young lady sitting next to me and her daughter. So thank you.

So one final question/comment is I understand deeply the need to address this growing challenge we have in our communities and seeing the impact that we can have, understanding and knowing that this is never going to be enough and we're constantly working towards building capacity and services.

The need is just so pressing that today I will be supporting this Bill. And I appreciate that you've been working to put in some amendments that raised an eyebrow for me. It's at a much better place for me and I'm happy to support it today.

Thank you, Senator, for bringing forth this Bill. I did—we've had several conversations, and our teams have as well.

I did want to just get to the question that was raised by Director Cabrera around perhaps the timing issue around the availability of housing and the urgency clause that's in this Bill, as well as the potential exponential, although we don't actually have a number increase with the addition of the bipolar one with psychoses in this.

And so, I don't know if it's a question for Deputy Secretary Welch or issues that you've thought about. So, having funding for housing is a very different proposition than actually having housing, as we know.

Have you all been able to map out, if you will, the availability of that housing by county and the potential increase of people who are participating in care court who would need to avail themselves of that housing?

We have not done that specific analysis. What I would say is that bringing people into housing is also a process, as you know, and not everybody—you do not have to be unhoused or to qualify for care court.

So, we've only been able to have some, really, in terms of validated data, I think it's roughly around half of our individuals are unhoused.

So, I just want to be clear that just because you qualify for care court, maybe even under the addition of bipolar 1 with psychotic features, that doesn't necessarily mean that you're unhoused and that you require housing.

And I think I would leave it to the doctor to assist with the numbers on how we're predicting how many people might this be. But again, this is not for people who are just diagnosed with bipolar 1 with psychotic features.

It's for people who have such impaired functionality that they would not be safe in the community without treatment.

So, I appreciate DHCS's recent report in July that outlined statistics that up until this point hadn't been reported.

And one of the ones that I was particularly impressed with and I think reflects the great work the counties have done, is of the CARE participants who were unhoused at the time of their petitioning, so 33%, 66% of those had obtained some form of housing.

So, I think that is encouraging. As far as the number of people who are, who would qualify under this new diagnosis. So, the lifetime prevalence of bipolar 1 disorder is about 1%. When we have statistics about upwards of 4.4%, that's including bipolar 1, bipolar 2, subthreshold bipolar disorder.

But bipolar 1 disorder is about 1 to 1.06% lifetime prevalence. When you're looking at bipolar disorder with psychotic features, that is obviously a fraction of that. So, about 0.24 to 0.74% of people with bipolar 1 disorder have also a diagnosis of with psychotic features.

So, with psychotic features is 2 out of about 10 specifiers of bipolar I disorder. So, when we're talking about bipolar 1 disorder, it really is a fraction when you're considering bipolar 1 with psychotic features. And then, you factor in all the additional requirements that are necessary to meet for CARE Act eligibility.

So, I anticipate that it would be a small number. And we have additional data from another court supervised AOT program that also shows that mood disorders are a fraction of participation when you're comparing to other counties, and this consisted of Los Angeles County, Nevada County.

There's also data from Contra Costa County, Orange County, that all say that mood disorders or bipolar disorders are a fraction of AOT participants. And the eligibility for AOT is severe mental illness. So, I do not think people with bipolar disorder, especially people with bipolar 1 with psychotic features, is an exponential increase.

Yeah, I just want to be very clear.

We worked very hard to understand the kind of the initial intent of the CARE Act and had struggled through Committee with the expansion of this to more broadly mood disorders, given the exponential increase in the number of people, and also, that this—it really broadens the original intent of the CARE Act to include people with mood disorders.

So, I just want to ensure that our Committee Members are focused on that as well. Director Cabrera, would you like to respond to any of the issues around the housing?

Thank you, yes. Absolutely. Briefly, you know, we did, in this budget that was just passed, cut the final round of behavioral health bridge housing. In addition, I will note, again, the monies under behavioral health bridge housing are already spent essentially. We're going to roll those over into BHSA, meaning the people who we house are people with significant disabilities.

They don't often just get a job and go out and afford rent in California. They often stay requiring subsidies. And so, the behavioral health bridge housing rolls over into BHSA. If we were to expand the population needing housing, we would need to bring in additional housing resources, but the more important piece is we have court ordered timelines.

We have to be responsive to the court within certain timelines under care court, and that means locating an individual, trying to engage them into services, and put together a report for the court. Those sorts of activities, really, it doesn't matter if they end up with a care plan or not. We still are held accountable for that.

And so, increasing the volume overall does have an impact on our staffing resources. Every petition that we have to track down is another person in need who we're not serving. And so, it really is a zero sum, unfortunately, at the end of the day.

And I just want to note that our NIMH estimates show 2.8% having bipolar 1. Half of that population has psychotic features. So, we're relying on NIMH data for those figures. Thank you.

Want to thank you, Senator Umberg, for bringing forward this Bill and certainly for your stewardship of this, of the CARE Act and the subsequent pieces of legislation. I know it is a passion point of yours and something that you have been very committed to ensuring that we're leading on.

I very much appreciated the conversations that we were able to have and that our staff was able to have on this. I think you heard some of the initial concerns about the broadening to mood disorders has been addressed in part with the amendments that you were able to take.

And I think this conversation around the timing issues, whether or not there's actual housing available, the switch of capacity and constraints on capacity that this will certainly cause for our county behavioral health system, I think is something that you are all too aware of as well. I just wanted to note that this is a really good conversation.

Perhaps you and I can do an oversight hearing on this in the fall at some point. I wanted to just articulate what the amendments were so that we are clear on them. It limits the expanded diagnoses under the CARE Act to just bipolar 1 disorder with psychotic features.

It strikes paragraph 2 and 4 from the clinically stabilized definition and clarify that enrollment and treatment alone shall not consider someone clinically stabilized.

And thirdly, strikes the addition of nurse practitioners and physician assistants from the definition of licensed behavioral health professionals, and instead, specifically includes them in a more limited role, allowing nurse practitioners and physician assistants to provide an affidavit as part of a CARE petition.

With these amendments—and I thank you for considering them and accepting them—I will be supporting this Bill and know that we have many more conversations to have in this area and very much look forward to a final report from the agency.

We've been relying on, on limited progress reports that kind of use the same timestamp to be able to evaluate the effectiveness and some of the challenges and opportunities with the CARE Act program, as it stands now, to be able to continue to make sure that we're refining our policy in a way that's aligned with the practice that we are experiencing right now.

And with that, Senator, would you like to close?

Thank you, Madam Chair. Thank you for your work on this particular issue as well. We focused here in this Committee on the Health Aspects. There are other aspects of this Bill too that are very, very important for the continuation, the improvement of the CARE Act.

So, let me just give you one other example that actually was heard in Judiciary Committee. That's where someone is charged with a misdemeanor who is incompetent to stand trial. And what we currently do is we just release them. So, if you've been shoplifting, you're clearly experiencing some kind of psychiatric disorder.

So, we bring you in, you're incompetent to stand trial and we put you back out under a bridge. That doesn't help anyone, certainly doesn't help public safety, nor the individual, nor the family. But what this does is it says that person then can be enrolled in Care court so that they can potentially receive treatment.

I do agree with Dr. Meyer in terms of the increase. I think the increase in population is very small.

But to be clear, the intent originally of this is where you see someone and we've all seen folks, and some of us, including me, have had family, lived experience in this space who's experiencing schizophrenia or psychosis, who's out in the street yelling at a stoplight.

But what we've done in the past is we bring them in, maybe put them on a 72 hour hold and we put them back into the community. What Care Court does, and clearly, we are resource constrained. I wish we weren't resource constrained.

But what Care Court does is for those individuals is we do provide a treatment plan that has accountability by a judge that has the ability to, for example, yes, order the county or order support system for that individual. So, I'm grateful for your support and I urge an aye vote.

Thank you. We have a motion from Aguiar-Curry, seconded by Patel. With that, secretary, please call the roll.

[Roll Call]

That measure's out. Senator, thank you so much. We are going to quickly do consent. We need a motion. From Patel, seconded by Aguiar-Curry. Please call the roll.

On consent. [Roll Call]

The consent calendar is out, and we will move on to the author that we have in the hearing room. Item 7, SB 503 by Weber Pierson. Thank you, Senator. Whenever you're ready.

Thank you, Chair. Good afternoon, Chair and Committee Members. Today I will be presenting SB 503, which would require specified artificial intelligence or AI technology to be identified, mitigated, monitored for bias impacts when deployed in the health care facilities. And this bill is also a priority of the California Legislative Black Caucus.

I thank the Committee for their active and meticulous engagement and will be accepting the Committee's amendments today. AI tools do not operate in a vacuum. They are created, trained, and deployed by people and each step in the development and deployment can be embedded with and reflect existing societal biases.

In healthcare specifically, decision support tools can be developed to assist with diagnosis, treatment plan, and resource allocation. However, if these tools are trained on incomplete, non-representative, or biased data, they risk reinforcing or, even worse, worsening existing disparities.

Without both proactive efforts and ongoing monitoring of their outputs, biased results can go undetected and uncorrected, leading to real harm in patient care. As a physician, I do see the promise that AI holds, but one of its greatest challenges is the risk of perpetuating bias and inequity when it is deployed without careful oversight.

We know the consequences of bias are severe, including shorter life expectancies, higher rates of infant and maternal mortality, psychologic distress, chronic life threatening diseases, and more for minority and marginalized groups. Several research and healthcare institution and organizations have already begun the work of creating pipelines that would assist in the identifying, correcting, and continuing monitoring of bias in their models.

Major large language model or LLM companies and nationwide coalitions recognize that these tools can reflect and perpetuate bias and have taken steps to address this by developing bias specific model cards, transparency frameworks, and comprehensive benchmarks.

SB 503 will specifically require that AI technology used in healthcare facilities to be identified if they support clinical decision making or healthcare resource allocation, mandate such tools be mitigated for bias, and ensure ongoing monitoring of those tools.

With me today to testify in support I have George Soares representing the California Medical Association and Dr. Steven Wang, a radiologist with the Southern California Permanente Medical Group and a leading voice in AI in healthcare. Respectfully ask for an aye vote on SB 503.

You'll each have two minutes. Thank you.

Hello, Chair Bonta and Assembly Health Committee Members. I'm Dr. Steven Wang. I'm a practicing radiologist in Bakersfield and an AI policy subject matter expert with the Southern California Permanente Medical Group and Kaiser Permanente. And as mentioned, I'm also the Chair of California Medical Association's Health IT Subcommittee.

I'm here today on behalf of Kaiser Permanente to testify in support of SB 503, which would require AI developers and deployers to make reasonable efforts to mitigate biased impacts when AI tools are used in clinical decision making and healthcare resource allocation. SB 503 would also require deployers to regularly monitor AI tools... Excuse me.

And take steps to mitigate such biased impacts. As one of the nation's largest integrated health care organizations with a long history of adopting new technologies and applying them at scale, we are leading the responsible use of AI across the health care sector.

We use AI tools to improve health outcomes and the patient care experience, and we use them without compromising patient safety, privacy, or the quality of our care. SB 503 is a measured and practical first approach in ensuring AI tools are safe and reliable. It is crucial for building trust in AI, as it ensures developers and deployers are responsible for taking proactive steps to mitigate biased impacts. And for these reasons, Kaiser Permanente supports SB 503 and requests your aye vote.

Thank you. Go ahead.

Thank you. Good afternoon, Chair and Members. George Soares with the California Medical Association. We're pleased to support SB 503, and we commend Senator Weber Pierson for bringing forward this important legislation to ensure that artificial intelligence tools and healthcare are safely and equitably and responsibly used.

Physicians and healthcare providers have long seen implicit and structural bias and how it can influence health outcomes, whether in diagnosis, treatment, or access to care. Our members rely on evidence based tools that uphold the ethical principles of equity and patient safety. Without reasonable and transparent evaluations, AI tools can risk reinforcing existing health disparities, particularly among underserved populations.

Ensuring these tools are tested for a protected characteristic bias is essential to maintaining trust, clinical accuracy, and equitable care for all patients. This bill ensures transparency and builds the kind of guardrails that give physicians more confidence in tools that they're being asked to use.

SB 503 is thoughtful, forward looking policy that balances the need for technological advancements with equally important responsibility to protect patients from harm. This bill will ensure developers and healthcare professionals collaborate, apply specific focus, and create pipelines to ensure these tools are identified, corrected, and monitored once they're deployed in the healthcare setting.

Physicians should feel empowered to play an active role and be assured that the tools that they are using are not silently biased against their patients, but are fair, accurate, and safe. We believe this bill promotes responsible innovation while keeping patient safety and equity at the center. We thank Senator Weber Pierson for her leadership on this issue, and we urge your support of SB 503. Happy to answer any questions. Thank you.

Thank you. Any others in the hearing room that would offer a me too in support, please come forward.

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

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

Dr. Catherine Forest, a consultant in malpractice with many cases associated with such bias, in strong support.

Thank you. Are there any primary witnesses in opposition in... Moved by Aguiar-Curry, seconded by Elhawary. Are there any me toos in opposition? Seeing none. I will bring it back to the Committee for any comments or questions. Thank you, Senator, and to your staff for your diligent work on this bill. The Committee hosted, as I think you know, a with Privacy Committee and informational hearing on AI back in May of this year. And we heard very clearly some of the issues that you are addressing.

That AI has tremendous potential to improve health care but is often subject to the many pitfalls, including instances of bias and hallucinations and particularly around race and gender. I definitely want to ensure that we are identifying and mitigating bias as a key responsibility for both developers and deployers of AI technology in healthcare applications. This came up in Committee and certainly was a subject of some consideration in your bill as well.

Just to make sure that we are clear on the amendments that we reviewed that will actually move forward with amendments to Privacy Committee that there's an understanding you will continue to clarify internally align the definition of deployer and the entities this bill applies to.

We also know that transparency from developers will be very helpful to assist employers address bias, and we encourage you to consider addressing this issue as well. I think in Health Committee. Sorry. In our informational hearing on this, there definitely seems to be a very big gap in terms of the willingness to take responsibility between deployers and developers.

And your bill is sitting right in the middle of that space because we know that developers have responsibility and ultimately deployers are in charge of ensuring that the maintenance of the large language models and the data sets are trained to be able to ensure that we don't have the kind of bias that we want to be able to prevent, especially as they're getting closer to clinical applications. So I understand you're taking those amendments. In your close, would you like to address any issues related to the developer deployer conundrum or anything else, Senator?

Want to really thank you and the Committee, like I said, for your help on this bill. This is something that we have been working on very diligently. It is a nuanced space. We are addressing those concerns and amendments when we take them to Privacy so that we can produce a bill that is implementable and actually has significant change and prevents further harm.

You talked about this being deployed in the healthcare space. It is deployed in the healthcare space right now. And some of those biases have already started to show up within how different patients are treated, or I should say also how they are into certain categories. So with that, respectfully ask for an aye vote on SB 503.

Thanks so much. We have a motion and a second. Secretary, please call the roll.

Motion is do pass as amended to Privacy Consumer Protection. [Roll Call]

That bill is out. Thank you very much, Senator. And for those staff who are watching with bated breath on your television, we are waiting for Senator Wiener, Senator Menjivar, and Senator Blakespear.

Hi, Senator. We'll be moving on to item number four, SB 68, by Menjivar.

I brought out the big guns for this one.

Senator, can you lift up her chair?

Thank you, Senator, whenever you're ready.

Good afternoon, Madam Chair and colleagues. I am here to present to you SB 68, and I will be accepting the Committee amendments. Madam Chair, Committee, or consultants, thank you so much for working with me and my team on this—a Bill that is really personal for me and personal for one of my witnesses.

I'll be speaking on her personal experience here. Currently, restaurants are not required to label significant food allergens on their menus. But if you've ever traveled to Europe, they do have that in the EU. I grew up as a bubble kid. That means that I was allergic to almost everything growing up. I've had gone through anaphylaxis.

I've been intubated, I've been in the ER. I'm allergic to about 70% of fruit and all the nuts that exist. So, when people say, snack on almonds, I can't do that. When I go to restaurants, I always am worried about what food am I putting in my system. I often ask the waiter, hey, does this have nuts?

Does this have that? And even in those conversations, I'll still be given a plate with almonds with nuts, because they will forget. Well, I get it. They're dealing with a lot of tables that they have to wait on. I get it's not their responsibility, but for me, it's my livelihood.

I need to make sure I keep myself alive. The nut allergy started at the age of 19 and I struggled that, I didn't understand.

I was eating at Red Robin once and I ordered a pesto pasta, not knowing that pesto is made out of pine nuts, and landed me in the ER with my mom, who thought her daughter was going to die at that moment. I was still, again, learning about my allergies.

It didn't dawn on me as a Legislator that two years ago, I could have introduced a Bill that addressed the lack of awareness of food allergens until a nine-year-old came to my office and said, hey, I have these allergies. What are you doing about it?

I was like, oh, my gosh, I have them as well and I'm not doing anything about it. Let's do something together. So, SB 68 is looking to do that.

If you're going to a restaurant, a medium—six or greater locations or a large chain restaurant—that when you get a menu, that on the menu it has the nine recognized allergens telling you what's in there: sesame, eggs, dairy, nuts.

If that restaurant only does QR codes for their menus, as we know a lot of restaurants do, then do the QR code and just put it on your digital menu. But not all of us are comfortable with QR codes and have that other paper menu available, should your customer request that.

Are you a smaller restaurant with less than six locations? Then you should have the flexibility with the amendments to address how—or have the flexibility on how you can share with your customers the allergens in your menu. Is that through a booklet?

Is it through a different way of displaying not being so rigid and how we want you to display it? Now, this isn't the first time this body has done something like this.

The very state Senator that held this seat of mine about 15 years ago, who is now the US Senator, did a bill on nutrition labeling and, and so forth. And a lot of the restaurants said it's going to put us out of business. We can't put all that, but they didn't go out of business.

And now, we get to enjoy the benefits of looking at the labeling of what's inside of our foods that we eat at restaurants and so forth. You might hear from the opposition that this is going to put them out of business. It's so burdensome. It's a false sense of security.

But we're living with the false sense of security right now. If someone just says X, Y and Z when we're having a conversation. We recognize that at the end of the day, it is our own responsibility to care for our own. No one else is going to care for us as we do ourselves.

But the studies show that when you couple having conversations with the waitress, waiter, and having awareness on a menu, you significantly drop the percentage of people having an allergic reaction that can turn fatal.

And unfortunately, a lot of the youth—a lot of the, the percentage of people who are coming across with food allergies are young kids, like the person next to me. So, we believe this has touched a balance that is providing the flexibility for restaurants, but also some sense of security.

Not 100, but some sense of security for individuals to be able to go into restaurants and not have to constantly be fighting for information on what they can eat. Madam Chair, I'd now like to turn over to my key witnesses in support of this Bill, starting off with Addie.

I'm Addie. I'm nine years old and I am in third grade. I'm allergic to dairy, peanuts, tree nuts, and sesame. I have had anaphylactic food allergies since I was a baby. I always have to be careful and carry my EpiPen wherever I go. But my EpiPen may not always be enough.

I have to avoid the foods I'm allergic to since it's like poison to my body and can harm me. But how do I know what's in my food to dine safely? At a store, I can check the label. The top nine allergens are clearly stated in bold. This keeps me safe.

At a restaurant, it's hidden like a secret. People may think it's easy to spot my allergens, like avoid cheese and don't drink milk. Obviously, avoid peanut butter. Nope. My allergens are often hidden. Chicken nuggets made with milk in the batter. Steamed veggies with butter. Cashew used for dairy-free cheese. Even my favorite food, dumplings, often have sesame oil in it.

Oftentimes, I have to pack safe food wherever I go. But this is not always possible. I want to be able to eat out with my friends and family like everyone else. How can I protect myself? When we ask the waiter, they don't know and often need to check. Most of the time, no one knows for sure.

Even when the chef knows, it's loud and busy. And it's like that game telephone. How do you know what they tell you in the end is true? If they're wrong, I won't just get a rash, I will get very sick. I could die. I have to trust what they say with my life.

There must be a better way. Please pass SB 68, ADDE, so that restaurants will label the top nine allergens on their menus. This will keep me safe. I want to dine allergy safe. I am one of 4 million people in California with food allergies. Please protect us. Please protect me.

Thank you so much, Addie. Go ahead. You'll have.

Thank you, Chairwoman. My name is Alexa Jordan and I'm here on behalf of the Asthma and Allergy Foundation of America, 500 medical professionals in California, and 67 state and national organizations in support of SB 68.

Currently, the Retail Food Code fails to set up guardrails for a particular set of food hazards that could cause very serious illness and in rare cases, death. Food allergens.

It's time that we address this glaring gap in public health here in the Legislature to protect Addie, Senator Menjivar, and the other 4 million Californians with food allergies by passing SB 68. Because there is no cure for this chronic disease, those affected must abide by strict avoidance.

However, avoidance is particularly difficult when you do not know what's in your food. SB 68 is a Bill about transparency. This lifesaving legislation adopts the global standard of written allergy information, a practice that has been mandatory in the EU and the UK for over a decade.

Assembly Members, I want to be clear that written allergen information reduces risk, supports staff, and protects restaurants. Right now, customers, as Senator Menjivar and Addie discussed, must rely on conversations with waitstaff who start with little to no information about the allergens contained within foods.

SB 68 gives both diners and waitstaff a written foundation so they can have more informed conversations to best limit risk and limit liability. Our legal analysis shows that SB 68 does not change the existing liability under current California law. Labeling for potential cross contact will remain voluntary under SB 68, just like it is for packaged foods under federal law.

People who live with allergies are well aware that conversations to prevent cross contact will always be necessary, with or without SB 68. We see SB 68 as a reasonable step that restaurants of every size can take to protect their customers. Ritesh Patel, the Board Chair of a nonprofit, has been a small restaurant owner for 16 years.

He told us that it took him two hours to sit down with a chef and redesign his menu. This two hour investment does not seem an unreasonable inconvenience to avoid preventable deaths, protect people, and avoid severe reactions for a large proportion of our population. We hope to celebrate California's leadership on written allergen information. Thank you.

Thank you. Are there any others that would like to join Addie in support for this Bill?

Good afternoon. Roxanne Gould. Great job, Addie. I'm with American Nurses Association California, in support.

Nisette Short, on behalf of Rady Children's Health, in support.

Ryan Hom, small business owner, two restaurants in San Jose. Board of Directors of the Food Allergy and Anaphylactic Team food allergy advocate got Obama to sign the Bill to get epi-pens in schools across the nation, Governor Brown, and also, my son at 18 died at a restaurant because there was no labeling of peanuts on the chocolate mousse.

Four years later, my other son ate at a fall restaurant eating their same dish—three years, same one. All of a sudden goes anaphylactic. He was saved because we got him to the hospital. But they changed the recipe, boiled the broth with peanut without labeling. Went back to the management, they said they would fix it.

13 years, no change? No. So we need this. It'll save lives. We need this on there. I'm a small business and we can afford to do it. Thank you.

Great job, Addie. I'm April with a Voice for Choice Advocacy, in strong support of this Bill. Thank you.

Allison Barnett with Platinum Advisors, on behalf of Fair Food Allergy Research and Education, support if amended. Thanks.

I'm Laura Parikh and as a high schooler living in the Bay Area, California, who's lived with fatal food allergies since infancy, I'm in strong support of SB 68, ADDE. Thank you.

Beverly Wong Jan from Santa Cruz, California. On behalf of myself, two children with life threatening food allergies, and several other family members with food allergies, I support this Bill.

Ursula Fontos, Nanny, in support of SB 68.

Hi, my name is Ryan. I support SB 68.

Kevin Guzman, with the California Medical Association, in support.

I'm Graham Mello, a classmate to Addie, and I support this Bill. Thank you.

I'm Ryan Miller and I support this Bill.

My name is Joy Miller, and I support SB 68.

My name is Kristen Miller, and I support SB 68.

I'm Jacob Light and I am a classmate—not classmate, schoolmate—of Addie and I support SB 68. Please let this Bill pass.

Hi, I'm Heather Light and I support this Bill.

My name is Zane and I support this Bill.

I'm Zane's mom, Caitlin Richter, and I support this Bill for my kiddos with food allergies.

My name is Journey and I support this Bill.

My name is Myisha McClure, mother, daughter, granddaughter, and aunt of loved ones with food allergies. I definitely support this Bill.

I'm Rachelle Lear, mom of two kids with food allergies, and I support this Bill.

I'm Alexandra Fanow, I'm one of Addies's classmates and I support this Bill. Go SB 68.

I'm Eleanor White and I'm one of Addie's classmates and I support SB 68.

My name is Cara Cooper, and I support SB 68. Dining out should be safe.

My name is Zuri Gonzalez, and I support SB 68. Dining out should be safe.

Seneca Gonzalez, CEO, Co-Founder, Harmony Legal. I support this Bill.

My name is Miles Gosnan, and I support this Bill.

My name is Enzo, and I support this Bill.

My name is Lucas, and I support this Bill.

My name is Ethan, and I support this Bill.

My name is Angela Mercer. I'm a Pediatric RN at UC Davis taking care of children who are recovering from anaphylaxis from food allergies. I support this Bill.

I'm Ryan Jackel, and I support this Bill.

My name is Rhea Jekyll, and I support this Bill.

My name—my name is Anu Jekyll, and as a mother of two kids with severe allergies, I support this Bill.

Jonathan Mello, parent of one of the classmates of Addie, and I support this Bill.

Cody Boyles, on behalf of Western Fair Association, we're happy to remove our opposition to the Bill. Thank you.

My name is Rubina, and I support SB 68. We want to dine allergy safe.

Hi, my name is Surah Ali. I have two kids with—they have severe allergy action, so I support this Bill. Thank you.

I'm Ella Finot. My daughter is Addie's classmate, and my daughter also has food allergies, so we support this Bill.

Good afternoon. My name is Rhianna Aghlubat. I'm a neonatal ICU nurse, and I support this Bill.

Good afternoon, Committee Members and Madam Chair. My name is Sabrina Tor. I'm 17 years old, from the Central Valley. I, too, suffer severe allergies, and I'm strong support of this Bill.

I'm Renee Reinhart, pediatric nurse practitioner. I support this Bill.

As a mother of Lara Parikh, who's had severe peanut allergies since infancy, I don't think any child should live with such fear. So, I support this Bill. And thank you, Addie.

Thank you, Addie. I'm extremely emotional because I live in paranoia and fear every single time my daughter goes out to dine. Thank you for starting this out, and I hope this passes. That will reduce the paranoia of parents like myself every time my daughter actually dines out. Literally. Pin pricks when she's out.

Thank you, sir.

Hello. My name is Rachel Arai, and I'm a mother of three children, one of whom has a severe peanut and dairy allergy, like Addie. We're in strong support of this Bill.

My name is Kengo Rai. I have anaphylactic peanut allergies. I support this Bill.

My name is Megan Almwina, and I've had fatal—had fatal allergies since I was an infant, and I support this Bill. Thank you, Addie.

My name is Alaina Lewis, and my mom has a severe shellfish allergy. I support this Bill.

My name is Avalon Lewis, and my mom has a severe selfish allergy. So, I support this Bill.

My name is Amy Lewis, and I have a severe shellfish allergy as well as an underlying histamine issue, mast cell activation syndrome, which makes it even more serious if I get exposed and I support this Bill.

My name is Abby, and I support this Bill.

Hello. My name is Dr. Celine Chandler. I'm a licensed pharmacist. I have family with allergies, and I support this Bill.

Hi, my name is Kylie Baranowski. I have severe allergies, and I support this Bill.

Hi, my name is Garo Pena, and I support this Bill.

Thank you so much. Are there any primary witnesses in opposition to this Bill? I'm so sorry.

I appreciate that, Madam Chair and Members, thank you. Matt Sutton of the California Restaurant Association. Definitely continue to be impressed by this group of advocates. So, we are close. We are opposed unless amended and I certainly appreciate the Chair herself's time, Committee staff, and of course, the Senator and her staff as well. So, I think.

I guess I would just say this. We have a very long—Matt Sutton with the Restaurant Association. We have restaurants that are the large chains, and then the vast majority of our restaurants are those independent restaurants. So, we have worked in this building for a very long time.

I've been with the Association for a very long time, and we've done at least two or three different allergy bills to get our side of the restaurant, you know, better educated. And so, we have staff training that's been required. We have content requirements in certifications for restaurant staff. We feel very good about what we've done.

Now, we're at the stage where we're dealing with SB 68 and how do we communicate with guests. And so, I think there's two things that we'd point out here. We have put forward a compromise with tremendous concessions that gets every diner in California allergen information at their fingertips. That's what we're proposing. That's what we have proposed.

There's two issues that have yet to be worked out. One is with liability concerns, and one is with what is the communication method to the guest. I'll start with the communication method to the guest. What we have proposed is called the National Model Food Code.

It is something that actually this Committee and its Senate counterparts spend a decent amount of time each session adopting elements of that food code. It is the gold standard for allergen disclosure. And what it does is it allows for three or four different methods, including on menu, including brochures, allergen grids. It's different resources that it allows.

And what I'm getting at here is as we're happy to provide the information, we cannot live with an on-menu mandate in every circumstance. This model food code is what's used in the rest of the country to communicate the message to guests. That's what we're asking.

SB 68 says you can have that for some restaurants but not the others. We're saying for consistency and for the benefit of the dining consumer, to give it to everybody. And again, it's a national model. That's what we're asking for. Super reasonable communication methods to the guest. The second piece is with regard to liability.

We understand that some of the liability language that we asked for and that was blessed by Judiciary Committee has been agreed to. But there's a sentence that was left out. That's the piece we're asking for and that's the piece that fits in the spirit of what was mentioned before by the Senator, with regard to Senator then Alex Padilla's Bill on caloric menu labeling.

There was liability information language put in there to protect restaurants acting in good faith. That's the spirit in which the language we've put forward meets. And that's—we're asking for one sentence back with that language.

And we're asking for this national model food code structure to be given to all restaurants and not just the select few in the Bill. Thank you.

Thank you. With that, are there any in opposition to the Bill in the hearing room? Seeing none. I will bring it back to Committee for any questions or comments. Assemblymember Elhawary

Addie, you are my hero. But also, I just really appreciate just the importance and thoughtfulness of being able to really look at how we ensure that allergens are on, you know, restaurant menus, especially being thoughtful around the type of restaurants.

But I did want to ask, just in terms of that one sentence, if there are thoughts that you have, as the author, around why that might have been left out and if there's possibility of being able to add it.

So, what we did was added the liability language that was requested by us from CRA. It didn't have exactly everything word for word, but what we came up with was after it was vetted by both the Assembly and the Senate Judiciary Committees to make sure that this was in line with current law.

What we weren't looking to do was to diminish current law or add to current law. So, this is the status quo liability clause that is included in other statutes that we have. So, we left it as is, as the status quo.

Assemblymember Schiavo.

Thank you so much, Addie, for your leadership. Senator Menjivar has a knack for finding young, brilliant kids to do bills with and I'm really grateful for this Bill. My kiddo has a dairy allergy.

And it's true, you can't, I mean, luckily, it's not anaphylactic, but you can't trust what people tell you at the restaurant because they can forget, they can forget a kind of flour that is used or a lot of times they don't think of butter as dairy for some reason.

I don't understand why and, and for us, it can be a really miserable night and completely change plans and if you're traveling, make life very, very difficult.

But when we were traveling in Europe and found that things were on the menu, it made a world of difference for our experience to be able to trust that my kid could eat. And, you know, it's something that unfortunately, we're behind on and will make such a difference in people's lives and lives—literally protect lives.

To consider as well. Well, Senator, thank you so much for bringing forward this Bill. I want to also thank Ms. Jordan for your testimony as well.

So, very grateful for this Bill. Happy to move it today.

Assemblymember Gonzalez.

Just out of curiosity as any, and I have not read if that particular piece was in there on menu specifically for other languages as well, or is it just in English?

That's a great question. Assemblymember. We haven't been asked a question on language. It's whatever the language of the menu is, it's going to be matching that language.

Just out of curiosity, just because of Spanish especially sometimes we forget like, oh, wait, we are allergic to that.

Assemblymember, the, the Bill stays, is silent and doesn't specify on that issue. But it is...

Thank you for bringing that to our attention.

And I think just to the opposition, we, Mr. Sutton, we were, we went back and forth a few rounds on trying to strike the right balance with making sure that we weren't creating anything that was too onerous, particularly for the independent, smaller restaurants that we know.

You know, a simple—it may seem like a simple thing to change a menu, but there's dollars in costs and time associated with that. And I believe that we struck a balance that is workable for now.

And while I appreciate the concerns around the additional sentence for the sake of the Assembly Health Committee, that issue is kind of asked and answered on the Senate side in Judiciary and we were able to amend kind of in concordance with what had already been discussed with, on the Senate side. And that is our pattern of practice.

So, while I appreciate that, I also think that there's some duplicative language with that additional sentence that exists in current law and felt like we were able to make sure that that negligence standard would be addressed with existing law. Addie, thank you for being an incredible nine-year-old who's able to tell your story.

And I just want to say that the things that resonated most with me and your testimony was this idea that I have to trust what they say with my life, which is incredibly powerful. And the simple idea of wanting to be able to dine an allergen free, I can certainly resonate with.

My mother has a very severe allergy to pepper. So, you can imagine the conversations that we have to have.

And nine times out of 10, after a 20 minute conversation to be able to figure out how to order a salad, as simple as that, chances are that something that she has eaten and consumed with the best of intentions, the greatest amount of care from the servers and the restaurant, the chef, the owners of the restaurant, can often result in her having a severe response to that.

So, I want to thank you for representing my mother, Addie, in this moment as well, with your advocacy around this piece of legislation. Senator, I know that you've taken the amendments that we have offered to this Committee and with that, would you like to close?

Thank you so much. Thank you for the, the comments. Thank you for bringing something up, Assemblymember Gonzalez. Thank you to, to my witness, Addie and Robin, for being so engaged in this.

We know that this isn't the end all, but we do know that when customers are informed, when customers inform their staff—when customers inform waiters of their allergies—53.9% of reactions still occur. When menus clearly show allergens, declare allergens, that number drops down to 26.6%.

When you combine showing it on the menu and having a conversation, it drops down to 13% to 14%. It's a combination of everything.

This isn't a sole magic pill that's going to stop all allergies from happening in California, but it's going to bring some great relief for the 4 million Californians like me, like Addie, who, every day, have to make sure what you're offering us is safe for us to eat.

And with your support today coming out of Assembly Committee on Health, we can make sure we bring that additional support to the 4 million Californians. Respectfully asking for an aye vote.

I think we have a motion. Do we have a second? Second from Rodriguez. Secretary, please call the roll.

Madam Chair, I do have a quick question and a comment.

Go ahead.

I wanted to express my gratitude for bringing this Bill forward. We have many community members who have extreme allergies, especially for families with young children, learning to navigate that health space can be very challenging. And having a transparent way to express that is great.

I had initial concerns around what about like, the corner deli and some other, like, smaller market type, you know, the grocery store, countertop restaurant that we have in our ethnic communities.

But I saw that you had made provisions to allow for a very simple way, a tiered way, that our smaller businesses and our ethnic markets can accommodate this, this new protection for our, our community members. So, thank you for doing that. I appreciate that. Making sure that our businesses can keep—can comply—is very important as we bring new legislation forward.

So, with that, I will support the Bill. Thank you.

Thank you. Secretary, please call the roll.

[Roll Call]

That measure's out. Thank you so much, Senator. Congratulations, Addie. We're going to move on to file item 6, SB 403, by Blakespear.

Hi, Senator. Please go ahead. Please go ahead and press the button

Thank you, Madam Chair, and hello colleagues. Nice to see this large Committee here. I'm pleased to author SB 403, which is sponsored by Compassion and Choices Action Network. This bill removes the January 12031 sunset for the End of Life Option Act, California's medical aid in dying law.

The legislature passed the End of Life Option Act in 2015 to give mentally capable, terminally ill adults with a prognosis of six months or less to live, the option to request from their doctor a prescription for medication that they can decide to self administer and die peacefully in their sleep. There are strict eligibility criteria.

Each patient must make two oral requests, a written request signed by two witnesses, and be evaluated by two different doctors to ensure that they are mentally capable and not being coerced. The person must be informed of alternative options such as palliative care, and the person can change their mind at any time.

In 2023, 1,281 people received a medical aid in dying prescription an 835 took the medication and passed. Nearly 93% were age 60 or older and 93.8% were receiving hospice and or palliative care at the time of death.

Since the law went into effect on June 9 2016 a total of 4,287 people have died following ingestion of aid in dying medication under the End of Life Option Act. 9 years of data show the law is working exactly as intended and medical aid in dying is being safely practiced in California.

No other medical aid in dying law in the country has a sunset date and a sunset is not a safeguard. SB 403 removes the sunset, making the End of Life Option Act permanent. Patients, advocates, medical providers, and faith leaders who rely on the law will no longer need to worry about access to medical aid in dying being removed.

And with me here today as my two witnesses, I have Catherine Forest, a Los Altos family physician who prescribes aid in dying medication, and her husband of 37 years, Will Forest used the law in 2021. And Bonnie McKeegan, LCSW.

She is a retired licensed clinical social worker with a background in mental health, chemical dependency and medical social work. Her mother, Pamela Harris, had breast cancer and accessed California's End of Life Option Act and died in 2018 at age 74. May my two witnesses begin?

Please go ahead. Thank you.

Thank you.

Thank you, Madam Chair and everyone. My name is Bonnie McKeegan. I'm licensed clinical social worker from Grass Valley. I'm here to urge you to support SB 403 to make the End of Life Option Act permanent in California.

I testified before this Committee in 2021 in support of SB 380, which was critical to removing barriers to accessing medical aid in dying in California. That work mattered deeply to me then, and it still does because in 2018, this law helped my mom have an end of life experience she desperately hoped for.

My mom was diagnosed with breast cancer in 1994. She endured all of the traditional treatments, surgery, chemo, radiation, and five years of tamoxifen. At the five year mark, she was considered a survivor with no evidence of cancer. 13 years later, in 2013, they found metastatic breast cancer on her shoulder, her spine, and her pelvis.

She begged my father and me at that point, promise you won't let me suffer. My mom had been a private home health aide for the terminally ill and watched my brother die of melanoma at 31, skin and bones with a catheter because of so much cancer in his belly and hallucinating about spaghetti when he couldn't eat anymore.

She also watched one of her breast cancer support group friends, her father, and her father in law die from cancer. She knew what was coming. She spent four and a half years doing every treatment available for metastatic breast cancer. All the smart drugs, radiation, and then chemo at the end. Nothing slowed it down.

On February 5, 2018, the day of her choosing, she used California's End of Life Option Act. She died peacefully in her sleep held by my father and me. She'd lived with cancer for roughly 25 years.

We have to remove the sunset for people like my mom who know years ahead of time the suffering that's coming and may want to consider utilizing this compassionate option. I want to know that the End of Life Option Act will be here if I am diagnosed with terminal cancer like so many in my family have died from. And I thank you and I urge your support.

Thank you so much. Please go ahead.

Thank you, Members of the Assembly Health Committee for allowing me to testify today. I'm here representing my own viewpoint and none of the organizations that I work for. My name is Dr. Catherine Sonquist Forest.

I'm a family medicine physician and professor, a public health specialist and someone who's prescribed medical aid in dying medication, and yes, a widow. I'm here to urge your support for SB 403 which will make California End of Life Option Act permanent.

In 2021, I testified before this Committee about my partner of 37 years, Will. That summer he was diagnosed with a motor neuron disease, now thought to be a rare complication of Long Covid. Within months, he lost his ability to walk and speak and eventually even to breathe on his own.

Will was a brilliant public health scientist serving the government for over 40 years and a deeply loving father. And after learning his diagnosis was terminal, he turned to me and said, Catharine, if you hadn't worked on this, on aid in dying laws, I would be living every last day of my life absolutely terrified.

The law gave him the peace to focus on the time he had, and left with our children. Even with access to excellent care, Will face still faced barriers. Our primary health system didn't participate, which meant delays that caused him intense anxiety whether he'd get the medication in time. And thankfully, he did.

One morning, after a particularly terrifying night of choking and gasping, he whispered to me, gather the kids, I'm ready. We rolled his bed outside, and surrounded by trees and his loved ones, he died peacefully. The compassionate option gave Will back a sense of control even as everything else was slipping away.

But unless you pass SB 403, this law will expire in 2021. And that means families like mine and patients like Will will face fear and uncertainty about whether they'd be allowed this option when they need it most.

Since the California End of Life Option Act went in effect in 2016, data collected by the CDPH shows that the law worked as intended for those who could access it. This aligns with nearly 30 years of national data on the effectiveness and safety of aid in dying laws.

And since the law went into effect, over 4,000 individuals utilized medical aid in dying and over 90% were enrolled in hospice or palliative care. And the the time, as was my husband. There have been zero complaints or allegations of coercion in that time.

SB 403 only removes the sunset provision and keeps all other elements of the law intact, including a multi step process for request, confirmation of eligibility, and opportunities for patients to change their mind. The continuation of the option of medical aid and dying is crucial for agency at the end of life.

As a physician who sees how important this law works on the ground, I urge you to vote yes on SB 403 and make the End of Life Option Act permanent for all Californians. Thank you.

Move the Bill

Moved by Aguiar-Curry, seconded by Rogers. And thank you for your testimony. We will now have anyone else in the hearing room in support, please come forward. And state your name.

Good afternoon. Roxanne Gould with the American Nurses Association, in support.

Thank you. Name, organization, and position only.

Hello, My name is Dr. Sara Pender, medical loss program support, Gerontology Department Chair, clinical psychologist, marriage family therapist, hospice bereavement coordinator and have seen many drug induced comas into death that were termed natural death. So I strongly encourage you to support this bill. Thank you.

Hi, my name is Rachel Poppers. I am an LCSW and a hospice social worker. I've supported many people through this process and I support SB 403. Thank you.

My name is Dolores Eitel. I'm a retired, as you can see, nurse practitioner. I have sat with and helped people take this safe medical treatment and I look forward. I've had cancer five times now and if I am in such a position that I would want that I am looking forward that I know where I live in this state, I can do that. And also I want to remind everybody that we are the only state that does not have the sunset. I mean, that has the sunset.

Good afternoon, My name is Christina Robel and I'm from San Jose, California. And this is Jingo. He came in to my bedroom screaming in pain. He had a cancerous tumor blow up and start to fill his lung with the cancer. I could help Jingo exit in a humane way.

Thank you, ma'am.

But if the same thing happens to me, I have no help. Thank you. Please pass it.

Hi, I'm Kate Rosenlieb and I'm in support of SB 403 and ask for your support. Thank you.

Thank you.

Hi, my name is Leslie Chinchilla and I'm in strong support of SB 403. Thank you.

Thank you.

Hello, my name is Dan Diaz. I'm Brittany Maynard's husband, in support of SB 403. Thanks.

Thank you.

Good afternoon. Dr. Clint Hopkins, owner, pharmacist at Pucci's here in Sacramento. Proud to offer this option to patients. So I can help them pass with dignity, in support. Thank you.

Thank you. Seeing no others in support in the hearing room, we'll move on to any primary witnesses in opposition or others who would like to offer an opposed position as a MeToo.

Nisette short on behalf of the Alliance of Catholic Healthcare, in opposition.

Brock Campbell from the California Baptist Capital Ministry on behalf of Freedom's Way Baptist Church in Castaic and Faith Baptist Church in Wheatland. Oppose this bill.

Emily Campbell with the Capital, California Capital Baptist Ministry, and on behalf of Lighthouse Baptist Church, I strongly oppose.

Molly Sheehan with the California Catholic Conference and the La Luz Coalition, in opposition. Thank you.

Thank you. Seeing no others in opposition, we will bring it back to the Committee for any questions or comments. Thank you, Senator Blakespear, I want to thank your witnesses for testifying with such grace and and for sharing your stories to give us some visibility and insight into ensuring that we offer compassionate care option to our community members here in California. I want to thank you for telling your stories.

Senator Blakespear, I know that this has been a passion project of yours for quite a while. I'm very thankful that we are able to address, have been able to address any of the concerns or considerations that the Committee had on this bill.

And I want to thank my colleagues for making sure to weigh the impact of this bill with the care that it deserves. Senator, would you like to close?

Yes. Thank you very much. First, I'd like to thank my witnesses for sharing their personal story and giving us some insight into what it looks like in two minutes to go through that.

And I'll just share that, I come to this topic from having just had conversations with the generation above me, my family members, about their lives when they look forward, but also having worked as an estate planning attorney and drafted wills and trusts and powers of attorney and advanced health care directives and had a lot of conversations with clients about this topic.

And as people are planning for their exit, their final exit, they think about the whole range of things, including how much autonomy and control and medical decision making they will have if they do have a terminal illness or if they don't.

And so the reality is that what we're doing today is relatively modest and that it's not expanding this law at all. It's just eliminating the sunset on a law that's been working well for 10 years.

So recognizing that we have provided the option for people with a terminal illness who are within six months of death to, to access medication that gives them the choice to take it is something that people have, they suffer with things that will happen years in advance, as one of my witnesses described.

And so there is anxiety that comes up if people are thinking that this law might expire. So it's important to me and to many that we eliminate the sunset and that we are then in line with the 12 other states that have this law and don't have a sunset. And so with that, I will respectfully ask for your aye vote.

Thank you, Senator. We have a motion and a second on this measure. Secretary, please call the roll.

[ROLL CALL]

That measure's out. Thank you so much, Senator. We have one more measure to hear. In the meantime, we will open the roll for add on.

Start with the consent calendar.

[Roll Call]

That measure is still out. Item number two, SB27 by Umberg.

[Roll Call]

That measure still out. Item number 4, SB68 by Menjivar for add ons. We're good on that one. Item number six, SB4 403 by Blakespear we just heard item number seven, SB 503 Weber Pierson.

[Roll Call]

That measure still out and we are going to hear a vote change on.

SB 68.vote change SB 68 Sanchez not voting to Aye.

We'll move on now. Thank you Senator for coming over to item number three, SB 41 by Wiener.

Thank you very much. Madam Chair, I'm here to present Senate Bill 41, which will require transparency and rein in abusive practices by pharmacy benefit managers that are escalating the cost of prescription drugs and killing community pharmacies. I want to note that recent amendments conform the bill to the health trailer bill that created licensure for PBMs.

And we're grateful to the Administration for its collaboration. And so should the bill pass out today, we will amend the licensure out of this bill as it is existing law. And I'm happy to accept the amendments in the Committee analysis as well.

So PBMs started out as small administrative entities created by health plans to help put together their formularies. And it was an administrative function. Fast forward several decades and PBMs are now corporate behemoths that are often bigger than the health plans and frankly are combined with health plans or own health plans.

They own their own pharmacies, mail order pharmacies that they effectively try to force consumers to use instead of community pharmacies. They've structured their compensation in a way where the higher the drug price, the more money they make because of the way rebates are structured.

And it's just a series of abusive practices that are not to the benefit of patients and not to the benefit of costs. Containing costs in the healthcare system and the destruction of community pharmacies is very severe because pharmacists play a critical role in the healthcare system.

And while some people may want to do a mail order pharmacy, for many people that simply doesn't work.

And the practices with pharmacies are I think, particularly abusive for anyone who's ever had a situation where you're told that if you go through the mail order you get 90 day supply if you want to go to your neighborhood pharmacy, you only get a 30 day supply.

That's one of the practices PBM's used to try to effectively force people to use their mail order pharmacies. There is broad bipartisan support for ending these practices both in Congress and in this Legislature. And this Bill will prohibit practices that steer patients towards PBM's own mail order pharmacies and away from community pharmacies.

It will also move away from spread pricing and will require will prevent PBMs from pocketing a portion of rebates, which is what gives them the incentive to favor high cost drugs and of course licensure, which is now part of the budget. This is a reform that is way, way, way over.

This Committee passed and the Legislature passed a similar bill last year while the Governor did veto it. We're optimistic that we'll be able to work with the Administration, particularly given the licensure being placed in the budget and we look forward to that conversation. So with that I respectfully ask for your aye vote on SB 41.

With me today I testify as Clint Hopkins, pharmacist and owner of Poochies Pharmacy here in Sacramento, and Dr. Sonia Frosto, the owner of 10 Acres Pharmacy.

Thank you. You'll each have two minutes.

Good afternoon, Madam Chair and Members. I am Dr. Clint Hopkins, pharmacist and owner of Pucci's Pharmacy. Independently owned here in Sacramento since 1930. PBMs now dominate not only the pharmacy market, but also the healthcare market at large.

They own the health plans, the pharmacy down the street, the mail order pharmacy to where they steer our patients, and they dictate contracts that underpay and force pharmacies to close. Even before the Rite Aid closures, there were numerous other community pharmacies closing their doors, creating pharmacy deserts.

We do our best to care for these patients, but too often we have to explain that the drugs they take are being reimbursed below the acquisition cost, a large part of the reason that their previous pharmacy closed their doors.

Every day it seems we spend more time explaining to patients we cannot help, why we cannot help them and trying to help them navigate the system than we do counseling patients who are actually picking up medications from our pharmacies.

PBMs limit drugs which can be dispensed locally and Reserve the most profitable drugs for dispensing from their own pharmacies. Just yesterday we were contacted by a patient who was forced to use a PBM owned mail order pharmacy for his specialty medication.

This patient happens to be a federal employee who is Forced to use the PBM owned Caremark Pharmacy who manages the benefits for federal employees. His medication is a generic that doesn't cost very much. He's not happy with the mail service.

He's run out of meds multiple times due to their delays, missing doses and putting him at risk disease, which could be prevented by allowing him local pharmacy access.

And then the kicker, they've been charging him a $60 copay each month when he could be just paying $50 cash out of pocket for this specialty medication from a local pharmacy like mine or Sonya's and had the medication the same day. Unfortunately, he's not an exception.

Just last week, another patient, a child of eight months old, who is being forced to use specialty pharmacy for sildenafil liquid for pulmonary hypertension. The average pharmacy would charge around $120 for a bottle of this medication.

We can observe from claims data that CVS will likely pay themselves in excess of $1,300 for the same medication sitting on the shelf in my pharmacy. And his parents will have to wait for this crucial medication to be shipped from a mail service pharmacy in another state.

For far too long, PBMs have operated in the shadows, extracting exorbitant amounts of money from the system they've designed. Without this legislation, PBMs will continue to run afoul, causing more pharmacies to close, local jobs to be lost, and patients lose access to health care in their communities. I respectfully ask for your aye vote on SB41.

Thank you. Go ahead.

Madam Chair, Members of the Committee, I'm going to get emotional, so I apologize in advance. My name is Sonia. I'm the owner of 10 Acres Pharmacy here in the Land Park area. As a local pharmacy, we are deeply rooted in our community.

We've built a welcoming space where care goes beyond prescriptions, where relationships are built on communication, respect and compassion. I work every day to empower my patients, but it's become nearly impossible to focus on their needs while fighting to keep my doors open.

I'm managing the pennies, literally the pennies, and determining what my reimbursement is because it comes daily. PBMs often reimburse us under what we paid for the drug. So I might pay $105 for a drug and being reimbursed $50, which leaves me $55 short. That doesn't even take into account my staff, my utilities, or even my loans.

This is truly unsustainable and it creates a situation where I have to decide whether I can even take care of this patient or I have to send them to a mail order or a chain block pharmacy that's down the street. This is just to keep my doors open.

This is not what I signed up for when I became a pharmacist. And this is not what any of us pledged to do when we took our oath in 2024. Our pharmacy had to let patients who had HIV, cancer and heart disease know we could no longer fill their medications because we were being re reimbursed below cost.

These aren't rare situations. They're happening every single day. The more prescriptions we fill, the more money we lose, the more financially unsustainable this is.

Now we have four pharmacies that have closed within a five mile radius of my store and I'm now having to choose whether or not I can take parents, grandparents or children because I'm losing money every single time. It's very painful to turn them away.

While most people don't realize why their local pharmacy closes, I can tell you firsthand it is the unchecked powers of the PBMs that is driving us out. And it's not just in Sacramento, it's across California. My friends down in Fresno have owned pharmacies that have helped Covid vaccines and distributed them. And guess what? They're now closed.

We need real action. We need you to sign and support SB4 41 to stop the PBMs from reimbursing below cost and driving pharmacies like mine out of business. Pharmacies are essential. Our patients cannot continue to suffer. Our pharmacies cannot continue to disappear. And I respectfully ask and respect your support. Thank you.

Thank you for that testimony. Very appreciated. All those in the hearing room who would like to offer a me too and support, please come state your name, affiliation and position on the bill.

Good afternoon. Shira Spector, with Stone Advocacy on behalf of the California Orthopedic Association in support. Thank you.

Thank you. Madam Chair and Members. Megan Subers, on behalf of the Los Angeles LGBT Center, co sponsor and support. Thank you.

Clifton Wilson, on behalf of the California State Association of Psychiatrists as well as the California Academy of Child and Adolescent Psychiatry Tree both in support. Thank you.

Good afternoon. Michelle Johnston, with the National Multiple Sclerosis Society on behalf of myself and others living with Ms. In support.

Fred Nowhere, representing the Pharmaceutical Research and Manufacturers of America in support. Thank you.

Good afternoon Madam Chair, Members. Andres Ramirez, with Blue Shield of California and strong support. Thank you.

Jennifer Snyder, on behalf of the California Life Sciences and the National Association of Chain Drugstores in Support.

Hello, my name is Celine Chandler. I'm a licensed pharmacist. I just completed residency at UC Davis Health and I support this bill. Thank you.

Erin Gilbert, for USC Keck School of Medicine and support.

Sarah Osito, on behalf of the ALS Association and support.

Hello, I'm Isaiah Cyboff, and I'm a Toro University student, a pharmacy student and I am in trunk support.

Chair and Members. Cathy Mossberg, on behalf of San Francisco AIDS foundation, one of the proud co sponsors, as well as APLA Health, both in support.

Hi there. My name is Andrew Gaboris. I'm a student pharmacist from Loma Linda University and I support this bill.

Faith Conley, with Weideman Group on behalf of the California Society of Health System Pharmacists and strong support.

I am Dr. Asha Malhotra, and I'm only representing myself. I support this bill.

Good afternoon. I'm Xiaodong Feng. I'm the oncology pharmacist and Professor and the dean for California North State University. I strongly support this bill. Thank you.

I'm Dr. Hongbing Wan. I strongly support this firm.

Good afternoon. Liz Helms, President and CEO of California Chronic Care Coalition, co sponsor of this very important building. Strong support.

Tim Madden, representing the California Rheumatology Alliance in support.

Luis Mailer, on behalf of Indivisible California State Strong and the 80 local groups that we represent in strong support. And incidentally, a regular customer at 10 Acres Pharmacy. In strong support of bill.

Kevin Guzman, with the California Medical Association in support.

Gilbert Laura, here on behalf of Biocom California in support.

Hello, my name is Ulisa Sorzada, student. Pharmacist from Torre University California, in strong support of SB41.

Hello, my name is Asada Sikhan Chan, student pharmacist at Toro University. I strongly support SB41.

Good afternoon. My name is Shawna Casillas, from Toro University in Strong support for SB 41.

Hello, my name is Ken Salvador. I am a student pharmacist and in support for this bill.

Katie Van Dynesel, with Health Access California and support. Thank you.

Hi, my name is Carly Trinh, student pharmacist from UCSF and I strongly support this bill.

Hello, my name is Judy Rose Barber, and I'm a pharmacy resident from UCSF and I strongly support this bill.

Hi, my name is Kelvin Kwok. I'm a pharmacist and a faculty Member of the City College of San Francisco Pharmacy Technician program. I'm in strong support of SB41.

Hello, I'm Satynder Sandu. I'm a local pharmacist and I'm strongly support this Bill.

Ann Sodergren, on behalf of the California State Board of Pharmacy in support.

I'm Zazieda. I'm a registered pharmacist. On behalf of Walgreens and every pharmacist I know, I strongly support this bill.

Hi, Nadeida Vizcara, pharmacy student at Turo University. I strongly support SB 41.

Hello, my name is John Bundo, intern pharmacist at 10 Acres Pharmacy and student at California North State University, and I support this bill.

Good afternoon. My name is Ethan George. I'm a student pharmacist at Western University of Health Sciences, and I strongly support this bill.

Hi, I'm Vicky Tran. I'm a student pharmacist and I strongly support this bill.

Hi, my name is Prabhjot Kaur. I am a student pharmacist and I support SB 41.

Hi, my name is Randy Nguyen. I'm a student pharmacist at Western University and I strongly support this bill.

Hello, my name is Anna Tran. I'm a student pharmacist at Western University and I strongly support this bill.

Hi, I'm Alexandria Yung. I'm a student pharmacist at Chapman University and I also strongly support SB 41.

Hi, my name is Sang Yoon Kim. I'm a student pharmacist at Chapman University. I'm strongly supporting SB 41. Thank you.

Hi, my name is Sean Kim. I'm a pharmacist serving pharmacy at California Pharmacists Association. I strongly support SB 41.

Hello, I'm Giovanni Hernandez, from the California Pharmacists Association, and I strongly support.

Madam. Chair Members Rand Martin, on behalf of The AIDS Healthcare foundation, which operates 12. Pharmacies across the state, in strong support of this bill. Thank you.

Hello, I'm Dr. Pete Tanarelli, pharmacist, and I strongly support this bill.

Hi, my name is Shahana Raza and I'm a pharmacist and assistant Professor at California Northwest State University, and I support SB 41. Thank you.

Hello, I'm Tarekasim and I'm a pharmacist. I'm in support of this bill. Thank you.

Hello, I'm Dr. Allison Hamm. I'm a registered pharmacist and I support this bill.

Dr. Wylie Mente, pharmacist, and I'm in support of this bill. Thank you.

Hi, my name is Angelo Sorio. I'm a student pharmacist and I support this bill.

My name is Sarah Nguyen. I'm a student pharmacist at California North State University, and I strongly support this bill.

My name is Harleen Bogg, and I'm a student pharmacist at California North State University, and I support SB 41.

I'm Jishan Sidhu, P4, student at CNU. And I support SB 41.

My name is Vanshpreet Singh. I'm a student at California North State University, and I support this bill.

I'm Suzanne Clark, at California North State University, and I support this bill.

Ryan Spencer, with the Crohn's and Colitis Foundation in support.

Susan Bonilla, on behalf of the California Pharmacists Association, co sponsors of the bill and very strong support. Thank you.

Chair Gonzalez, on behalf of my clients, the American Diabetes Association, as well as the Bleeding Disorders Council of California, formerly known as the Hemophilia Council of California, all in strong support. Thank you.

Thank you. Are there any primary witnesses in opposition to the bill? Please come forward. There are two primary witnesses in opposition. Thank you. You'll each have two minutes.

There we go. Good afternoon, Chair and Members. Allison Ramey, here today on behalf of the Pharmaceutical Care Management Association in opposition to SB 41. It's worth noting that SB 41 is a reintroduction of SB 966, which was passed by this Legislature but vetoed by the Governor last session.

With the veto message being this, that he wanted greater transparency across the drug supply chain. This Legislature just last week passed AB 116, the health budget Trailer Bill, which achieved many of those goals for the Governor.

PBMs will now be licensed and regulated at the Department of Managed Healthcare and required to report an extensive amount of data to the Office of Healthcare Affordability, including claims data, contract terms, reimbursement rates at independent pharmacies versus affiliate pharmacies, and a whole lot more.

With that data, this Legislature will soon be informed and able to make educated policy decisions about how else to regulate the drug supply chain and specifically PBMs. SB 41 goes far in that it proposes additional policy changes that take away client choice and tie the hands of PBMs in their negotiations against drug manufacturers.

Left unchecked, we are trusting that drug manufacturers will lower the price, the list price that they set out of the kindness of their hearts.

I don't think that that world exists, and as a result, our concern is that the price of prescription drugs or will only go up for consumers and the patients that we are trying to make them more affordable for. It's important to remind this Committee that PBM clients do not have to use PBMs.

PBM clients being unions, the state plans, large employers, make the decision to use PBMs because they save them money. Nothing in SB 41 will lower the cost of prescription drugs for patients.

And while we appreciate the time and work that the Chair and this Committee have put into this bill and this issue, we remain opposed out of concern that it will only increase the cost of prescription drugs. And we urge your no vote.

Thank you. Go ahead.

Thank you, Madam Chair. Members, John Winger, here on behalf of America's Health Insurance Plans. We're the National Trade Association for the Health plans. As PCMA stated, our health plans voluntarily enter into arrangements with PBMs to lower their drug spend. But in the interest of time, there's multiple parts of the bill that we think would increase cost.

But in the interest of time, just focus on two things that the plans generally have issues with in the bill. One is around ERISA Preemption, and the second is around client choice. And so I think there's multiple provisions of this bill that we believe violate ERISA.

There was a 2020 ERISA court case that was upheld unanimously by the Supreme Court that affirmed laws are preempted by ERISA when they impact the core function of health plan Administration or directly relate to the health plan and their benefit design. And we think there's multiple provisions of this bill that violate ERISA.

On the client choice, as was mentioned by PCMA, we think that the PBMs offer an array of choices to the client on how they want to pay for the services. Some of those arrangements can be done in a way to kind of mitigate risk on the payer side. This bill would essentially get rid of those options.

And so we do have issues with that as well. And so for those reasons, we are opposed.

Thank you. Any others in the hearing room that would like to offer an opposition position on the bill?

Madam Chair and Member. Stephanie Watkins, on behalf of the Association of California Life and Health Insurance Companies, also opposed.

Good afternoon. Olga Shiloh, on behalf of the California Association of Health Plans, also opposed. Thank you.

Thank you. With that seeing no other opposition, I will bring it back to the Committee for any comments or questions. Assemblymember Sharp-Collins, thank you so much.

For bringing forth the Bureau of. Senator, I do have a question of. Clarification to the opposition, and I know the opposition. You stated that the way the bill is currently written that it will not lower the prices of the prescriptions to the consumers. So if that is the case, then. What other alternatives do we have? What options?

What all could we actually do to lower the prices for the consumers?

Well, I mean, I think one thing that we try to do as pbms is to the extent that there are generics available, those are what we are encouraging and have preferred placement on formularies.

What we see happen oftentimes is drug manufacturers that actually do everything they can to prevent generics from coming to market because they don't want that competition. And I don't know that that's necessarily something that this Legislature can tackle.

But some of PhRMA's tactics to reduce competition stand directly in the way of the ability to have lower cost drugs available to consumers.

Please.

Yeah, I mean, clearly there are issues to deal with with the pharmaceutical industry, and this Legislature has done that. And it's, you know, there's more work to be done in Congress as well. But we know that, in addition to whatever issues with pharma, that PBMs also escalate drug costs. Because the way they're, one of the practices we're banning in this bill, which again, licensure is great. I support it. I'm glad it went on the budget. That doesn't ban any particular practices.

The way that PBMs get compensated via taking a cut of the rebates that they negotiate with the drug manufacturers means the higher the drug cost, the higher the rebate, the higher their take. And so that's why sometimes on drug formularies, for example, lower cost insulin, or sometimes only higher cost insulin is on the drug formulary because the PBMs make more money from it. So, you know, there are a lot. So they are absolutely contributing to cost escalations.

I'm just noticing. Did you want to comment because you have some disagreement?

Yeah, I would just say we fundamentally disagree with that. I mean, PBMs get hired to negotiate the lowest net price on the formulary as possible, and those rebates go towards reducing the overall drug spend. And it's been seen in the SB 17 reports that it helps to lower and keep premiums down. So we would just fundamentally disagree that.

And I think to your original point, we would just say stop taking tools away in the tool chest when it comes to being able to negotiate drug prices. I mean, I was around for AB 339, the Gordon bill, which was kind of capping the co-pay, but it also had provisions in there that kind of mandated where we had to place drugs on certain formularies, which essentially gave our playbook away on being able to negotiate.

And so things like that have made it tougher to negotiate. There's things in this bill around banning exclusionary contracts to where it would make it tougher to do formulary placement, which would allow us to lower the cost of the drug. And so I think just, yeah, allowing our tools to remain in the tool chest would be our ask.

Thank you.

I'll add to that that when drugs go generic, PBMs often keep the brand name on their formulary for months and years after those drugs do go generic. I have examples that I can provide you, such as Vyvanse. Vyvanse is now generic. The generic cost a fourth of what the brand name cost, but the brand name is required by some plants. It's called the DAW9 program.

So even though the generic is available and it's cheap and we can get it, the plan prefers the brand and the patient may have a copay that's higher than what they would pay out of pocket for the generic. Not only Vyvanse, but there's inhalers, there's name some other examples, Sonia. Insulins.

Farxiga came out generic last year. Farxiga cost about $600. The generic is $150. Patients have to pay usually their $2,000 deductible at the beginning of the year. They're paying the most of that cost, $400 to $600 for this prescription, even though there's a generic available because the insurance plan requires that the brand be billed, which is not fair.