Senate Standing Committee on Health

The Senate Committee on Health will The Senate Committee on Health will now come to order. Good afternoon. File item six, SB 1252 from Durazo and file item seven, SB 1280 by Senator Valladares have been pulled from today's agenda. That leaves us with nine bills on the agenda. Two of them are on our proposed consent calendar.

That is file item number one, SB 912 by Senator Cervantes with amends. And file item two, SB 1271, Senator Reyes. Seeing that we do not yet have a quorum, we will begin as a subcommittee and we will begin with the first bill to be heard as I see the author is here. Thank you so much for being here on time. File item number two, SB 1124 by Senator Archuleta. You may begin when you are ready.

Well, thank you madam chair and doctor. I'm so proud to say that. Well, this one's gonna go right exactly where it should hit you home. But, again, madam chair, I'm presenting Senate bill eleven twenty four, lung cancer screening. And, I'm hoping that, when the rest of the committee comes back, they'll accept, the amendments and and everything we've we were gonna discuss today.

So, Senate bill 1124, as I presented, once again, I accepted committee's amendments, reducing the penalty, which was an issue from $1,000 to $500 per your request. And, Senate bill 1124 would require the California department of public health to create signage for lung cancer screening eligibility criteria. It would also require that signage be displayed at the point of sale locations for tobacco products.

Lung cancer is the leading cause of cancer death in California nationally, yet Californians have the lowest lung cancer screening rate in the country. The primary barrier is awareness, given that sixty two percent of Americans don't even know that lung cancer screening tests exist.

In 2024, an estimated sixteen thousand nine hundred and twenty Californians and residents were diagnosed with lung cancer, and 9,320 died from the disease, which is more than from any other cancer such as ovarian and leukemia. And and these cancers even combined don't measure up to that number. Eighty percent of patients diagnosed with lung cancer at an early stage are alive twenty years after the initial detection.

However, in California, only 25.9 percent of lung cancers are diagnosed at an early stage, which is significantly lower than the national rate. To address California's particularly low screening rates and the disparities in access across communities, Senate bill 1124 will require signage created by the California department of health for lung cancer screening eligibility criteria and the point of sale for tobacco products.

Madam chair, you know, in our communities, yours, mine, we have so many people that yet continue to smoke and it's devastation to the families. And we're talking grandparents and grandmothers, aunts and uncles who are in their sixties and seventies and still to this day continue to smoke. And I think this is awareness and this is what this bill is about. But with me today, I have Doctor Alex Zhu and, Sisi Tsai with the American Lung Cancer Screening Initiative.

If I can have them come up.

Yes. Good afternoon. Thank you so much for being here. You will both have a combined total of five minutes for your presentation.

Hello, Madam Chair, Weber Pearson and the members of the committee. Thank you for the opportunity to testify in support of the Senate Bill eleven twenty four today. My name is Cece Zai and I am a student at UC Davis but also a member of the American Lung Cancer Screening Initiative or ALSI. We're a student led organization that is dedicated to raising awareness for lung cancer screening.

And this issue is deeply important to us because many of the family members and community members that we, see are usually diagnosed with lung cancer at a later stage where it's already too late for effective treatment.

And through Aussie, I was able to speak directly to Californians at health fairs and also community outreach events across the state. And in these conversations, I have seen that many people have never heard of lung cancer screening and even when they may be eligible for the USPSTF guidelines. Now compared to other recommended cancer screenings, lung cancer screening rates remain far lower and I've seen that's about fourfold. And and one major reason is low public awareness.

Now many people who qualify for screening either not know that screening exists or not do not realize that, they may be eligible or unaware that the screening itself may be at no cost to them through Medi Cal.

And under current USPSTF guidelines, eligible individuals include adults that are between the ages of 50 to 80 who have a significant smoking history, who are currently smoking or have smoked within the past fifteen years. And yet people have never heard of these criterias and so therefore, they don't realize to ask for these screenings. There's also confusion for lung cancer screening on what it entails. It's basically, a screening that's done through a low dose CT scan, which is noninvasive.

It's quick and has very low dose of radiation, and providing just clear information at the point of sale with the SB 1124.

I think it would help reach individuals with higher risk, by providing just, like, clear, potentially life saving knowledge, about early detection and also cessation resources. So this bill is simple, but a meaningful step towards closing that awareness gap, about lung cancer and helping more Californians learn about, screening before it is too late. So I respectfully, ask for your support. Thank you.

Madam Chair, Weber Pearson and the members of the committee, thank you so much for the opportunity to speak in support of SB 1124. Thank you to Senator Archuleta for, and the co authors of this bill for for introducing this bill. I we think this bill is extremely important. My name is Alex Zhu. I'm a general surgery resident physician at UC San Diego.

I'm also a research fellow at the Massachusetts General Hospital clinical trial, looking at lung cancer screening in high risk populations. One of the things that we found in our in our study so far is that we we go out to the community and we try to recruit patients. And one of the things that we found is a lot of patients don't understand or don't know, you know, what lung cancer screening is.

And from the patients that we found, we've been able to identify cancers that that were found at an early stage, which is treatable. Unfortunately, the for the vast majority of Americans, they only sixty two percent, sixty two percent of Americans do not actually know that lung cancer screening exists.

And here in California, really only about one to some studies say up to ten percent or so, actually undergo lung cancer screen. As comparison nearly seventy percent of Californians, of California women at risk of breast cancer actually get screened, over the last couple of over the past two years. And this is especially especially striking, when the plurality of patients are diagnosed with lung cancer at stage four when it cannot be cured.

And when it's caught early lung cancer is highly treatable and patients often go on to live long healthy lives. After the surgeries, a lot of our patients tell us that, you know, they don't they well, if it wasn't for lung cancer screening, they still wouldn't they wouldn't be here.

So in California already mandates notices about the legal age of purchasing tobacco products, but nothing about educational lung cancer screening. Adding a notice about lung cancer screening is a low cost actual addition that would reach millions of high risk citizens in the most underserved communities and undoubtedly save thousands of lives. Thank you to the committee for the opportunity to speak today, and for considering s P eleven twenty four.

Thank you. If there's anyone else in the audience that would like to speak in support of this bill, this is your time to come to the microphone. State your name, your organization, and your position.

Afternoon. EJ Aguayo on behalf of the California Academy of Family Physicians in support. Thank you.

Thank you. Alright. Seeing no one else who's coming forward, if there is anyone that would like to speak as a lead witness in opposition to the bill, this is your time to come forward to the table. You will have five minutes for your presentation.

Appreciate it. Thank you so much, madam chair. Jack Yanos on behalf of the California Fuels and Convenience Alliance, despite representing the majority of small mom and pop convenience stores and gas stations here in the state of California. Wanna start off and first thank the committee and the staff that are trying to work on the bill. Really appreciate that, as well as the author's willingness and openness to engage.

The reduction in the fine from a thousand and $5, we do think, is a is a definite improvement in the bill. We do still have a concerns position on the legislation at this stage, mainly for what I would say are implementation concerns. Those kind of fall into two buckets. One bucket is, the size of the signage. Some of our folks have very small footprints, so just ensuring the signage is really appropriate for the smaller stores is really helpful.

And also ensuring that the CDPH is providing the signage to our stores so they can display it would be would go a long way in helping this bill. The second part, I would say, is also notification to our retailers. Right now, obviously, with the fine, there's no right to cure currently in the bill.

So getting our folks the opportunity to know what their obligations are under the bill so they can get the signs up and be in compliance with the law, will go a long way to addressing their concerns. So at at at this stage, we have a concerned position.

But again, thank the author and the committee for their work.

If there's anyone else in the audience that would like to register their opposition, they can come to the microphone now. State your name, your organization, and your position.

Hi. Good afternoon. Leticia Garcia with the California Retailers Association. Also, I wanna echo our concerns. And we do have a concerns position but appreciate working with the author and his staff and the committee.

Thank you. Seeing no one else from the audience that would like to come and speak in opposition, Senator, wanna thank you so much for bringing this bill forward. You know, we have done a very good job in the area of tobacco on educating, Californians, educating residents here in this country about the harms as far as the link to lung cancer. But we have fallen short in terms of educating them about the preventative screening. We talk about breast cancer screening, cervical cancer screening, colorectal screening.

Thank you.

But we do not talk about lung cancer screening. And, and so this is truly a gap as we are seeing numbers fall for people who are smoking. It's not at zero. And we know that there are also other ways in which people can get lung cancer. And so allowing for people to have that awareness, that one, there is such a thing as lung cancer screening.

And two, what would qualify you to be eligible for that screening I think is extremely important. I understand the concerns of the, of the opposition and I think that they are things that you all can continue to work out. I don't think that they are major, major obstacles that you can't come to, an agreement or a resolution about. So I really wanna thank you for bringing this bill forward, for authoring this bill, and I would love to be a co author.

And, at this point, you may close.

Well, thank you, madam chair. If anyone should be a co author, it's you. And I appreciate that and I truly acknowledge it and I appreciate it. But I also want to share something else with you. When I was in the military, you can imagine a platoon of men standing and there's a break for whatever reason and they would say light them up.

If you don't have one, bum them. Because the one next to you probably has one. So let's share those cigarettes. And, at 18 years of age, there it went. 18, 19.

And next thing I know, my buddies are smoking in their 20s and 30s and 40s and we've come home from deployments and they're still smoking because of what picked up in the military. Because it was macho. It was the right thing to do and so on. And not knowing that we were tearing up our lungs.

And so on behalf of my veterans that I serve and represent as the chair of the military affairs committee, I ask them to please be aware of the cancer and not just themselves, but their friends and relatives and everyone else.

And I think this bill will bring awareness to that issue. And, yes, we're gonna work out the size of the sign that might be in the store. But I will tell you this, if it's that small store, it's probably our neighborhood. Think about that. Read between the lines on that one.

So we'll adapt the signs, but we wanna make sure that sign is up there. And we've already made the adjustment from a high dollar amount to $500 since we talked this morning. And, but also more importantly, we also have the time to come back if they violated it, to come back and say, please display this sign, and then come back thirty days later, make sure it's still there. So we're not trying to be punitive. We just wanna be informative, And that's the key.

And if we can stop one gas station or two or liquor store across California, imagine the lives we can save. So with that, I ask for your aye vote.

Thank you, Senator. At the appropriate time, once we've established quorum, we will get a motion and vote on that bill. Thank you.

Thank you.

Alright. I see, Senator Jones has come in. And, before he comes to the podium, I would strongly encourage any other authors who have bills that they wanna present in health to come down and also, strongly encourage any members of the committee to come down. So, Senator Jones, file item number three, SB 1150. You may begin when you're ready.

Thank you, Madam Chair. It's an honor to be with you today in presenting, SB 1150, which addresses the lack of consistent patient notice when cancer cases are reported to the California Cancer Registry. I wanna thank the chair and the committee staff for their work on this bill, and I will be accepting the committee amendments, as, suggested by the Chair. The under the current law, specified entities are required to report cancer cases to the Department of Public Health.

The registry collects identifying and clinical information for public health tracking and research purposes.

While a notification requirement exists in regulation, it is not being consistently followed in practice. Notification practices vary across providers, and evidence from practitioners across specialties indicates that many providers are unaware of the notification requirement or the associated materials. Many patients only become aware of their information has been reported after being contacted by third party researchers researchers rather than at the time the report is made. In the era of HIPAA, it is widespread and and reasonable assumption among patients that their medical information is being kept private.

It is imperative that patients made aware that patients are made aware of the sharing of their medical data when it occurs.

SB 1150 helps increase patient awareness of the California Cancer Registry by requiring clear accessible notice at the point of care. I don't believe we do. No.

Thank you, Senator. If there is anyone who would like to, either speak as a lead support witness, this is your time to come up. Not seeing anyone. If anyone would like to come and register their support as a me too, this is your time to come up to the mic. State your name, your organization, and your position.

Seeing none, if there's anyone that would like to speak in lead opposition, please, this is your time to come to the table. Not seeing anyone. If there's anyone that would like to register their opposition for this bill, please come to the mic. State your name, your organization, and your position.

On behalf of the Public Health Institute and our colleagues at the Cancer Registry of Greater California, we wanna thank the author and his staff for working with us on this. We wanna thank the Chair and your staff for working with us. We appreciate the amendments. We think that it gets us a a long way. We still have to share the language with our colleagues at the registries, but we really appreciate that.

And we look to we look to look at wanna work with you moving forward, as the bill moves. Thank you for your time.

Good afternoon, Madam Chair. John LeClan on behalf of Keck USC School of Medicine. We also had concerns with the bill that was in print, and we stand ready to continue working with the author and committee and other stakeholders as this moves forward. Thank you.

Good afternoon. Jen Chase on behalf of the University of California. We also had a concern letter on the bill in print, but look forward to continuing conversations moving forward.

Seeing no one else in the audience that, would like to come forward and speak, Senator, thank you so much for bringing this bill forward. I know this is a bill that you have worked on multiple times. And it's an important issue. People who have been diagnosed with cancer, if their name is placed on a registry, should at least be aware that their name is there. And I think, you know, everyone should agree with that.

It's not stating that they can remove their name. It's not stating that you're going to have to ask them for anything. But at least, allow them to be aware.

You know, as as you know, in digging deep into this issue, it's it has come to my attention that, there is a requirement out there, that requires cancer reporting facilities and physicians to employ a mechanism to ensure that their patients are informed, that cancer has been designated as a reportable disease, and that the facility will report each patient with cancer to CDPH as required by law. That is a requirement that's already on the books for facilities and physicians.

I thought we can just give them the pamphlet at the oncology department. And then I realized that within the cancer reporting regulations, it's not just cancer, it's also cancer in situ, which I had no idea as a as a gynecologist that anyone that I had diagnosed with the c I n three, which is cancer in situ. We don't consider that to be cancer. We don't send them to an oncologist.

That it was my responsibility to inform them that they were now being, their names or information was being sent to this California cancer reporting regulation.

And so, trying to figure out how can we get this information out there. Because now what you're talking about based on this regulation is that every single physician would have to be educated. And every single physician would have to be held accountable. Whether you are an oncologist or you're a dermatologist that does skin biopsies. Or you are a GI doctor that does biopsies of the colon for a colonoscopy.

Or you're a gynecologist. Like every single provider, whether you are managing true cancer patients or just patients that might have insight to, which we don't consider to really be cancer, would be responsible for this. And so the only way I could think that we could do that is with this signage. And so, I really appreciate you working with us, working with me. I know I was coming back, you know, every day with a different idea.

But it is an important issue for people to know that their that their information is now in a registry. It's already law that they're supposed to know. It's interesting now that I've discovered who is the which which patients qualify for this registry. But I really want to thank you for continuing to work on this issue to continue to educate us, even myself about this issue. And I will continue to work with you to make sure that we get it right.

And along with any concerns that opposition may have. And if you would allow me to, I would love to be a co author on this panel as well.

Yep. Yeah. I think that would be very appropriate, to have you on. As you may know or or may not know, some of the advocates and some of the stakeholders know that this was born out of a constituent in my district several years ago that came to me very upset that she had been, contacted by the the cancer registry. She did not know that there was a cancer registry.

And for whatever her personal reasons were for keeping her cancer diagnosis private, she kept it private. She didn't even tell her own family, that she had cancer. And then she was obviously surviving and recovering. And then when she gets a phone call out of the blue from a third party stranger asking her very specifically had her cell phone number and asking very specific detailed questions about her cancer diagnosis and treatment. She was very shaken and taken aback by that.

When she brought that to me, I was like, this cannot be right. There's no way this is right. So I started digging into it. And as a cancer survivor myself, in, in with, in night from in 1999, discovered, yes, I'm on this cancer registry as well, without knowing it. And so now it became a little bit personal.

But it it's it's obviously across the population in California. I was getting a little choked up because I'm thankful that USC Keck is here because they literally saved my mother in law's life. But she's a cancer survivor too and doesn't know that she's in the cancer registry. I mean, obviously, she knows now. But I wanna thank you as Chair for taking this serious.

We've, you know, this is I don't know, fifth, sixth, eighteenth time. I don't know how many time we've times we've tried this. And each step of the way has been has been positive and and moved the ball forward because it obviously, you know, started originally with a lot of misunderstandings on both sides of the and I don't I don't even think there's two sides of the issue. There's multiple sides of the issue.

But but it started with a lot of misunderstandings that each time we've we've tried to, you know, get through those misunderstandings of the privacy issues, the the the purpose and the of the cancer registry and the good work that they're doing.

And I'll I've said it from the beginning. I'll restate it today. This is not about the cancer registry. I support the cancer registry. They do good work.

The people that are part of those cancer registries that are qualified to have access to this information are good people that are doing good work. But people just need to know. And so, you being involved in this, being the Chair of this committee now, I obviously, again, back to taking it serious, digging deep into it, and discovering more things than than I even knew, issues about it.

I'm really excited about working with you on this and getting it, getting something well done this year on it to fix the problem. So with that, I will ask for your aye vote.

Thank you.

Thank you. I think, Senator Varadares wanted to. Oh, I'm sorry.

Yes. Well, first of all, this was news and surprise to me as well. And, one, I'd love to be added as a co author. Two, I've told this story, you know, many times in in different committee hearings and on the floor about my mother's own, diagnosis, with pancreatic cancer and her passing of that as well. I had no idea that she is on some list until this bill.

Is there any way of notifying the next of kin as well. I mean, maybe that's a longer conversation. There's more work to be done on this. But I do believe that, you know, this is a very sensitive topic. I think most people who have had cancer, have, known someone to have cancer, whether they are survivor or or passed, are supportive of the research and the data.

I mean, I think we all say those, you know, four letter words about cancer all the time. But understanding what's happening with your information is is very basic from my perspective. So would love to dig more into this issue with you and love to be a co author.

Thank you very much.

Happy to move the bill when we have quorum.

Not seeing anyone else. You know, Senator Valladares, one of the the the benefits to the amendments is that everyone is now aware. So when you go into your hospital, when you go into your clinic, they see that sign, then they will know that hey, if you happen to have a cancer diagnosis with the way we, you know, are designating that. As of right now, your name will be in that registry.

So you will know that if your loved one got a cancer diagnosis and they choose to disclose that to you, then you will be aware of the fact that that they that their name or their information has been sent to that registry.

So if you would mind. So would that would it would that mean that the signage is placed in in what type of. Is it oncology office? Where where where is where is the sign?

So, we had kind of gone over this earlier. The way that we have it in our regulations, it's not just cancer, it's cancer in situ as well. And so because of that, pea people who are diagnosed with cancer in situ, you know, if it's, cervical cancer you've got CIN three or you know, VIN three or VIN three. These are gynecologic things. The same thing happens in any specialty.

Cancer reporting regulations, even they are reported. And therefore, we can't just focus on oncologist because those patients don't go and see oncologist. So this would be in hospitals and clinic settings whether it's primary care, gynecology, pediatric, like any anyone who sees a patient, has the potential to diagnose someone with, cancer in situ. And therefore, everyone should be aware that if you have that diagnosis of cancer or cancer in situ, the way things are being read right now, that they would be reported to our cancer registry.

Thank you. Thank you.

So Senator Jones, I know you had done a close but you can

I'll still use that as my close and thank the committee and the members for all their hard work on this and appreciate the energy moving forward.

Thank you. And once we get a quorum once we have a quorum, we will take the motion that Senator Valladares has done and take it up for her. Thank you.

very much. Thank you.

Alright. I see Senator Arreguin is here. So we will move to file item five, SB 1,400. Senator Arreguin, you can begin whenever you are ready.

Well, thank you very much madam chair, members of the committee for the opportunity to present SB 1400. First, I will be accepting the committee amendments, which clarify that Alameda Health System can maintain the private nature of health facilities that it affiliates with, rather than the facilities it assumes ownership of. SB 1400 will modernize the governance structure of the Alameda Health System, providing Alameda County with enhanced flexibility to improve oversight, operational efficiency, and the fiscal sustainability of local public hospitals.

And this follows a multi session, multi year review process, stakeholder review process, not just the county officials, but also labor, which created an ad hoc committee on governance, to identify gaps in the current governing structure at the delegation of operational responsibilities for AHS. The proposed statutory amendments reflect the ad hoc committee's determination that added flexibility will provide the board with a more direct role in key and targeted issues that impact AHS, including labor relations and personnel.

SB 1400 allows the board of supervisors greater flexibility to ensure that supervisors or county staff can sit on the board of the Alameda Health System given the significant impacts of changes in our health care system and how those impact the quality of care. It's important to ensure that those that we elected to represent are more directly engaged in these discussions. Current statutory authority limits governance flexibility by requiring the governing board that is appointed by, but legally distinct by the Alameda County Board of Supervisors.

Since that structure was established, the health care policy environment, as we know, has become significantly more complex. With the passage of HR 1, along with other federal and state policy changes affecting coverage reimbursement and delivery system requirements, There is a need for timely coordination between county leadership and our public hospital system.

In this evolving environment, the Alameda County Board of Supervisors has expressed a desire for a greater flexibility to be more directly involved in strategic oversight and system level decision making, particularly as we're navigating the new fiscal and operational challenges affecting our safety net providers. At a time when our public health system is under pressure, we need transparency, accountability, and leadership that protects patients as well as our workers.

And this bill is about making sure that Alameda County's public hospital system can continue to serve the most vulnerable residents in our county. I'm carrying this. This is a district bill.

Our trauma center and primary acute care hospitals in the city of Oakland, which I live in, Highland Hospital named after former supervisor Chan. But there are hospitals throughout Alameda County from Oakland all the way down to center Wahab's district, and this is a very important issue to make sure we can maintain this essential health care coverage at a time when it's needed most.

With me to testify in support are Amy Costa on behalf of Alameda County, and Tawanda Gilbert, the chief soft steward, for SEIU ten twenty one with the Alameda Health System.

Thank you. You all will have a combined five minutes for your presentation.

Great. Thank you. Good afternoon, madam chair and members.

I'm Amy Costa, Full Moon Strategies. I'm here on behalf of the County of Alameda. Unfortunately, the board has a budget work group meeting today, so a member of the board cannot be with you personally. The bill before you as the Senator explained is the result of a very deliberative local process. Over the course of a year, the board of supervisors convened an ad hoc committee on the Alameda health system governance model.

Through six separate sessions, county leadership, health system experts, and community stakeholders were brought together to take an honest look at what is hap what is working within the system and what is not. We reviewed multiple governance models as part of the process, including whether the Board of Supervisors should take a more direct role or continue delegating their authority to an independent board.

After those discussions and by consensus of those who participated in the process, we moved forward with a model that gives flexibility to step in where needed while still pervert preserving operational expertise and independence where it matters most. What we learned through the process is that our current structure, while well intentioned at the time, is not nimble enough for today's healthcare realities. As we look at the stark realities of HR 1, we wanna be nimble in our coordination particularly around labor, personnel, and system wide decision making.

SB 1400 allows the county board of supervisors to serve as the governing body or appoint others and explicitly allows the board to delegate day to day operations while maintaining their accountability. This at its core is about making sure our public hospital system can continue to serve the most vulnerable residents in our county and our community. The county studied the issue, built consensus, and put forward a thoughtful solution. SB 1400 simply gives us the tools to implement what our community has already determined is needed.

With that, I respectfully ask for your aye vote.

Thank you. Thank you.

Oh, hello. Okay. Good afternoon madam chair and committee members. My name is Tawanda Gilbert. I am the chief shop steward of John George campus that's located within the Alameda County structure.

I've worked for Alameda Health Systems for the last past fifteen years. And currently at the John George Psychiatric Hospital, I serve as a mental health specialist. AHS is the critical safety net for our community, and it employs 300, 3,800 union workers who are committed to patient care and that has never changed. Today, I'll be speaking about why we need assistance to continue to evolve AHS to meet the most for the moment of and need I'm sorry. I'm a little nervous.

In 2023, an ad hoc committee identifying gaps in the current structure and call for more direct involvement, especially on labor and system wide decisions. SB 14 will modernize AHS governance and give Alameda County Board of Supervisors the oversight needed to ensure accountability, stability, and better decision making. This past winter, we saw that mattered when AHS moved to make deep cuts to staffing that would have reduced services and harmed patient care. These layoffs are on hold, but the decision making remains a concern.

At a time where our public health system is under pressure, we need transparency, accountability, and leadership that protects both the patients and the workers.

I respectfully ask for your aye vote, vote on SB 1400.

Thank you.

Thank you. If there's anyone else that would like to register their support for SB 1400, this is your time to come to the microphone. State your name, your organization, and your position only. Thank you.

Hi. My name is Maria Betancourt. I'm a specialist clerk working at John George Psychiatric Facility, part of Alameda Health Systems, and I support SB 1400 and urge your aye vote. Thank you.

Thank you.

Good afternoon. Beth Madowski, the SEIU California, in support.

Thank you. Seeing no one else, if there's anyone that would like to speak as a lead witness in opposition to SB 1400, please come forward now. Not seeing anyone. If anyone would like to register their opposition, this is your time to come to the microphone. State your name, your organization, and your position.

Not seeing any. We'll bring it back to committee if there's any questions or comments. No? Alright. Well Senator, thank you so much for bringing this bill forward.

If you'd like to close, you may.

Respectfully ask your aye vote.

Thank you. Have your time.

That's a great close. At the appropriate time, we will take a motion to take that bill up. Thank you. I would also, offer any authors who have any bills to come down to health committee now if you'd like to present.

Yes.

10. Got it.

We're now gonna move to file item number 10, SB 1094 by Senator Weber Pierson, who is recognized when she is ready.

Alright. Well, good afternoon. I am here to present SB 1094. Half of all Californians report that their healthcare costs are rising faster than their paychecks. For too many Californians, that means delaying care or going without it altogether.

One underlying driver of rising health care costs are the cost of prescription drugs, which has increased by 72% since 2017. Biological products are particularly expensive. Despite comprising only 5% of all prescriptions, biologics account for over half of all drug spending. These are critical treatments, but their high price tags are putting a real strain on patients and our healthcare system in general. Fortunately, we have the opportunity to lower costs without compromising care.

Lower cost alternatives like generics and biosimilars offer the same the same safety and efficacy as their brand name counterparts at a significantly reduced price. In some cases, such as with the biologic Humira, switching to a biosimilar can reduce cost by as much as 85%. And when biosimilars enter the market, they introduce competition that helps bring prices down across the board. Yet despite these clear benefits, biosimilar uptake remains relatively low. This bill takes a practical approach to promoting biosimilar use.

It allows health plans to require patients to try a generic or biosimilar when it is available at the same or lower cost, unless a prescriber indicates otherwise by adding a do not substitute to the prescription. It also allows pharmacists to substitute a biosimilar for a biologic when appropriate, unless the prescriber indicates otherwise by adding do not substitute to the prescription. The Treburb analysis estimates savings as follows. 3,740,000 in cost share savings for those patients who switch to a biosimilar.

Around $90,000,000 in savings in the form of reduced premiums.

With me today to explain how this bill will make healthcare more affordable while maintaining high quality care is Nick Luisa from the California Association of Health Plans, and Susan Shea from Sharp Health Care. Thank you.

Thank you. You're both recognized for a total of five minutes.

Great. Thank you, Chair and Members. Nick Luizos here on behalf of the California Association of Health Plans. We're proud to be the sponsor of SB 1094, and we thank doctor Weber Pierson for her leadership on this critical affordability measure. We know that health care affordability is top of mind for policy makers and for their constituents.

This is why our association is actively working to promote policies like SB 1094 to drive down spending while expanding access to FDA approved drugs that are safe and effective. Consider the data between, 2017 and 2024, drug spending in California rose by a staggering 72%, and we cannot sustain that trajectory without bold policy shifts. As the author stated, the independent analysis is clear. There are both premium and out of pocket savings for consumers resulting from this measure.

And I'll just say, you know, in my nearly twenty years with the California Association of Health Plans, I've reviewed countless reports from SHERBURB, and I can't remember a SHERBURB analysis showing a decrease in premium growth until this bill.

So, this is momentous, in that regard. So SB 1094, as the author already explained, achieves these results by simply updating outdated statutes to reflect modern science, FDA clinical evolution, and follows Medicare policy where they've allowed for the automatic substitution of safe, this is a common sense update and, is carefully crafted with, extensive consumer protections, transparency, notification rules, and reporting requirements.

And this is why you see a broad coalition of of support which includes labor, the business community, and consumer groups, including, you know, our association. So, we need more solutions like this to lower cost in healthcare, and we urge your support for this bill.

Good afternoon. My name is Suzanne Shea. I'm a licensed pharmacist with more than forty years of experience and currently serve as the vice president of system pharmacy and clinical nutrition at Sharp Health Care in San Diego. I oversee medication use, compliance, and affordability, including our Sharp Drug Formulary Committee. Sharp Health Care is deeply committed to delivering high quality affordable care to our patients.

As part of that commitment, Sharp Pharmacy team uses a cost based approach to review all medications for safety, Eff Effectiveness, and then cost. This approach has generated significant savings for our health system and for our patients. As these lower cost alternatives that include both generics and biosimilars have reduced our acquisition costs and lowered our out of pocket expenses for patients. So to give you an example, Usintiq is an FDA approved bio similar for the Stelara, a brand name biologic product for the treatment of psoriasis.

As a biosimilar, Usintech has been found to be as clinically effective as Stelara by the FDA.

And the price for us centric is 97% lower than Stelara. Under current California law, pharmacists are authorized to substitute generic versions of prescribed medications unless the prescriber explicitly prohibits the substitution. But the same state authority does not currently include substituting biosimilars per for prescribed, reference biologics, even when the biosimilar is an FDA approved and clinically, equivalent, Stelara and Yesintiq.

This means the Sharp Pharmacy team must undertake additional time consuming steps, includes including multiple calls, oftentimes to individual prescribing physicians to clarify treatment plans and switch these medications. These administrative hurdles take physicians away from their patients and can delay patient care.

SB 1094 removes those barriers by providing pharmacists with the authority needed to make these prescription changes to biosimilars the same way we'd have for generics and help protect our limited health care dollars for everyone. Thank you.

Thank you. We'll now move to anyone else in the room that would like to express their support. Please state your name, the organization, and your position only.

Good afternoon. Tim Taylor with the National Federation of Independent Business in support.

John Winger on behalf of America's Health Insurance Plans in support.

Katie Van Dynes with Health Access California in support. Thank you.

Good afternoon. Andres Ramirez with Blue Shield of California in support.

Stephanie Watkins on behalf of the Association of California Life and Health Insurance Companies also in support.

Good afternoon. Beth Malnowski, the SAO California in support.

Aliyah Griffin with the American Federation of State County Municipal Employees in support.

Megan Murray on behalf of the California Society of Health System Pharmacists in a support if amended position. And we thank the author very much for the ongoing discussions.

Anthony Butler Torres on behalf of the California Hispanic Chambers of Commerce in support. Thank you.

Good afternoon. Mandy Isaacsley on behalf of CES Health in support.

Thank you members. David Gonzalez on behalf of America's Physicians Groups in support. Thank you.

Afternoon. Ej Aguayo on behalf of the California Academy of Family Physicians in support.

Good afternoon. Medica Stegarskiya here on behalf of PCMA in support.

Alexis Rodriguez with the California Chamber of Commerce in support.

Thank you. We'll now move to any key witnesses in opposition of the bill. Please come forward. You're each recognized for a total of five minutes.

Thank you, Madam Chair and Members. Brian Warren with the Biotechnology Innovation Organization. We have an oppose unless amended position. Our concerns are limited to the pharmacy substitution provisions and we first of all thank the author and her staff for their, receptiveness to hearing our concerns. Our position is based on the different licensing standards in federal statute for the distinct categories of biosimilar and interchangeable biologic.

To be approved as a biosimilar, a product must have no clinically meaningful differences in terms of safety, purity and potency. But they are not tested for therapeutic equivalents. Comparing this to generic drugs, only therapeutic equivalent products may be substituted by pharmacists. Many prescribers and pharmacists are familiar with FDA Orange Book, which list products as, with therapeutic equivalents evaluations. This bill would treat all biosimilars as if they were therapeutically equivalent even though that is not the case and has not had been proven through their licensing standards.

FDA has already taken steps to increase the substitution of biosimilars. And they've done this through the process that is outlined in federal statute, which is by streamlining the process to obtain the interchangeability designation. So those are the products that have shown that patients can switch from one product to another without any clinically meaningful differences in their treatment outcomes.

Allowing pharmacy level substitution of products that have not demonstrated they have meet the standard of interchangeability eliminates the ability of the FDA to say which products can be substituted safely, as well as which products cannot be substituted safely. I'd also like to point out the pharmacy substitution already occurs under existing law.

Interchangeable biologics can be substituted without any intervention by the prescriber, and non interchangeable biosimilars can be substituted with a phone call to the from the pharmacy to the doctor's office, as well as an integrated care settings that can be done in a more, streamlined way. It's important to however those safety standards that exist under existing substitution are not recognized in the process outlined by this bill, which is why we have our concerns. Thank you.

Madam Chair, Members, Tim Madden representing the California Rheumatology Alliance in opposition to SB 1094. First of all, I'd like to thank the author and the author's staff. I think we've spent, north of two hours talking through our concerns on the bill and are very appreciative of the time in listening to our perspectives. Our concerns are centered around the impact SB 1094 will have on rheumatology patients and rheumatologists' ability to provide what they believe is best care for their patients.

The conditions that the conditions patients have when seeing a rheumatologist are quite unique in that there are no cures.

The most common condition rheumatology patients have is arthritis. Patients with these conditions experience chronic aching, throbbing, sharp or burning sensations. For some patients, the pain renders them unable to get out of bed, go to work, or have any type of functioning life. Treatments center around trying to find the best medication that will help the patient. This is not always straightforward and can often take months, even years, of trying different medications to find the one that works best for the patient.

Biosimilars can be an effective choice, but every patient is going to react differently to a biosimilar. And the experience of rheumatologists is that there are some patients who have negative reactions when switched. A larger concern is around multiple switching that occurs between biosimilars and the lack of notification by the pharmacist directly to the physician when a switch is made. One example I was told was a patient being switched from one biosimilar to another three times over a four month period.

The physician did not become aware of the multiple switches until the patient came into the office after four months and was complaining of a rash.

The rheumatologist was left with trying to figure out which biosimilar caused the reaction and then what to prescribe to get the patient back on track. Removing the physician from the decision making process for the care is particularly frustrating. Lastly, an additional challenge with the pharmacist switching medications is the lack of knowledge and access the pharmacist has to a particular patient's medical history.

A rheumatologist was sharing a situation when a patient was switched to a biosimilar they had already tried while with a different health plan that did not work. Since the pharmacist did not know this and was not in contact with the rheumatologist, the patient ended up going on to the biosimilar with the same ineffective outcome.

Rheumatologists are not opposed to patients being on biosimilars. Our concerns are how the bill is further removing the physician from being able to provide what they believe is the best care for these patients. Thank you.

Great timing. Thank you. We'll now move to anyone else in the committee room that would like to express their opposition. Please state your name, your organization, and your position.

Matt Back representing the Osteopathic Physicians in opposition.

Good afternoon. Gilbert Lara here with Biocom, with an oppose unless amended position. Looking forward to working with the author's office. Thank you.

Thank you. Seeing no others, I'd like to bring this back to the committee. Senator Durazo.

Updated information. But, opposition says or, well, actually, what I have in front of me, the notes are that the plan must give a thirty day notice to the doctor and then the doctor has the ability to disagree and then not not allow it to the change to move forward. Is that I just heard opposite of that that the doctors are removed for the decision making.

Thank you, Senator, for the question. So the bill has two parts. There's one part that deals with the pharmacist making a switch and then a second part that deals with the health plans making changes. So you're correct that as it relates to the health plan, they do, they would be required to give thirty days advance notice to the physician, which we think is a good thing and we're appreciative of that amendment that was taken. So that'll give our, that kind of gets to our point.

It gives our folks an opportunity to say, okay, let's take a look at this and then we have an opportunity to work with the health plans if we think there's a different course that's effective. So it kind of brings us back into the loop as compared to the pharmacist side where that is not the case.

The pharmacist can make that switch without giving any prior notification to the physician which is where we've kind of centered our concerns is on that side versus what, the thirty days notice part.

So from my understanding, and we can continue to have conversations, the provider would get a thirty day notice. And then once if the pharmacist chose to was able to make that switch that the provider would then be notified within five days that that switch had been made. So it's not that providers are not being notified of this. That's number one.

And number two, providers like with generics at this point, if I write a prescription, I want my patient to get the brand name and not the generic.

I can always say do not substitute, check the box, do not substitute. So if a provider did not want his or her patient on a biosimilar, they always they still have that option of saying no.

I'm sorry. So if you could further explain why the difference between doing this with the pharmacist and not the health plan. So the The difference.

The pharmacist is already in law. Right? That's already current statute. So if a pharmacist switch, they have to inform the provider within five days. That's already law.

We took an amendment to go a step further with this bill to have the insurance companies also inform the providers thirty days before.

Okay. I'm not quite sure.

We could have aligned with current law, which is only five days, but we gave them for the insurance companies thirty.

So did you have any questions, Senator?

So just to kinda clarify to get to the bottom of from the patient perspective. When a patient goes to their doctor and they are prescribed, you know, whatever it is. And they go and the doctor's prescribed a certain prescription. There's no the doctor doesn't say whether or not they wanna opt out of a biosimilar being used. So the patient then goes to fill that prescription at the pharmacist, and the pharmacist would tell the patient, oh, you have a cheaper option, x y z.

Would you like to use this prescription or this biosimilar instead.

So it's similar to what happens now with generics. When you get a prescription from your provider, you would go to the pharmacist. You may end up with that specific name or you may end up with a different medication.

Depending on what they have in stock as well, you typically.

Depending on what they have in stock, depending on what your insurance, which brand your insurance covers—generic brand or whatever your insurance covers. And at that time, the physician is also notified: ‘Hey, I know you prescribed ABC; however, your patient was given CDF based on the fact that it’s generic, and this is what the plan covers.

So I'm not understanding from the opposition, because notification is happening. It's it's thirty days, but it is happening from both the pharmacist and from now the health plans. I'm not understanding how there is concern that this could impact, patients negatively in terms of their treatment, especially when it's my understanding that pharmacists have a pretty significant knowledge of what, the side effects are of every prescription.

So I have a disconnect. It's important your opposition but I'm having a disconnect in understanding that.

Thank you madam chair if I may. So a couple of things. One is that the side effect profiles of biosimilars and their reference biologics should be the same. The concern is that patients sometimes have different treatment outcomes when they're on established course of treatment of a biologic and switch to a biosimilar. The other thing is that the provisions that require a health plan to provide thirty days notice to a doctor are not limiting factors on what the pharmacist authority would be given by this bill.

Does not say that if the health plan refuses to provide notice to the doctor or if a patient just walks in, that the pharmacist is not allowed to substitute a non interchangeable biosimilar as would be allowed under the bill. So they are if you required the pharmacist to give thirty day prior notice to the doctor before switching, then that would be alignment, I think, with what the way some people are perceiving the health and safety code sections of the bill.

But those would also need to be in the business and professions code.

Okay. So if, one, I would like to establish a quorum so we don't lose anyone. So we can do a real quick pause and then we'll come back to you. Secretary, please call the roll.

[Roll Call]

Yay. We have a quorum. So it it seeming like, the sponsor's health plans would like to weigh in and probably Doctor. Weber Pierson as well.

Yeah. I mean, I think, you know, one of the things that we're hearing from the opposition is that they're trying to basically leave you with the impression that, you know, biosimilars that don't meet this, what we would just call a pretty meaningless interchangeable designation. They they wanna cast, you know, some sort of doubt on them.

And I'm just reading from the FDA fact sheet that all biosimilar products meet the US Food and Drug Administration's rigorous standards for approval for the conditions of use described in product labeling, patients and health care providers can be as confident in the safety and effectiveness of the biosimilar as they can be for the reference product. So I mean and that and they include interchangeable or otherwise.

So they are moving away from that. And I think, you know, what the opposition is trying to do is try to cast some doubt on their efficacy or safety, which is just not what the FDA is say saying at all. In fact, they're decidedly moving away from all that. And so we have the right, you know, you can go your own way. The BNP Yeah.

I said I would weave a song lyric into this. But but, you know, this the pharmacy provisions of this bill were debated pretty thoroughly in BNP, and it passed 10 to 0. You know, the committee analysis in that committee, you know, definitively stated that, you know, pharmacy level substitution is within the authority and of the state and is governed by state law.

Senator Weber, would you like to close as well.

Sure. I appreciate, all of the conversations with the opposition, as was stated by the sponsors of this bill. I mean, it's I'm also looking at the FDA, sheet that basically states that, the reference project, which is would be considered like the brand name, the biosimilar and the interchangeable, all meet FDA's rigorous approval standards. They're all safe options. They're all effective options for patients.

And, you know, when we talk about potential side effects, you can have potential side effects to any medication. And that does not prevent pharmacists from switching a patient from brand name to generic. And that's why one, we do have that notification. But two, just like if I prescribe something for you, you got a generic, you had a rash from it or something, you would call me, I would immediately tell you to stop, write the new prescription, say do not substitute. It's the same way.

And so, you know, I think in this situation as was stated, I don't remember seeing any kind of analysis that really talks about saving money. And we are really focused on ways in which we can lower the cost of health care. And at the core, that is exactly what this bill is about. It's about affordability. It's about access, which are really key important, components of adherence.

It's about making sure Californians can get the care they need without having to choose between their health and their financial stability. We have many safe, effective, lower cost alternatives to the staggeringly expensive biologics available today. But we're not using them to their full potential, and we are seeing the repercussions of that in our very high and continued rising health care cost.

This bill offers several practical ways to encourage biosimilar use to bring down cost and inject more competition into the system that pharmaceutical manufacturers have controlled for a very long time. 4 out of every 10 Californians are struggling with medical debt.

6 out of 10 Californians report skipping medical care due to cost. And 7 out of 10 Californians are more worried about medical bills than the price of housing or utilities. We all know these numbers. We all see these statistics from the surveys that we've had. We need to get serious about addressing the rising cost of health care, and this is one piece of that puzzle and I respectfully ask for an aye vote on SB 1094.

Thank you.

Do I have a motion. Senator Caballero moves the bill. Secretary, please call the roll.

The motion is do pass and re-refer to the Committee on Appropriations.

Senator Weber Pierson, aye. Weber Pierson, aye. Valladares, aye. Valladares, aye. Caballero, aye. Caballero, aye. Durazo, aye. Durazo, aye. Gonzalez. Grove. Menjivar, aye. Menjivar, aye. Padilla. Perez. Rubio. Smallwood-Cuevas, aye. Rubio, aye.

That is 6 to 0 and still on call.

Thank you. We are now going to move back in the file to file item nine, SB 1314 by Senator Menjivar. You may begin when you are ready.

Thank you, Madam Chair. As a state, we are confronting a growing youth drug crisis from the surge in our youth, vaping among teens to the recent rise of nitrous oxide use, commonly known as whippets.

We are seeing, emergency departments are seeing a surge of visits from individuals because of nitrous oxide or their misuse of nitrous oxide. There have been reports of middle and high school students seeing their peers carrying these canisters in their backpacks and even at times inhaling this on school campuses.

Repeated use of whippets can cause severe neurologic, cardiovascular, psychiatric effects, including hallucinations, delusions, organ damage, nerve damage, seizures, coma, and even death in some cases.

And it doesn't help that at the same time that we're seeing these several reports, the places that are selling these things are popping up near school sites. When kids are walking to school, what are they seeing constantly? Our smoke shops. Smoke shops. For some reason, these smoke shops have targeted their locations near sensitive areas.

In 2025 alone, 14.2% of tobacco retailers, which includes smoke shops, liquor stores, gas stations, convenience stores, deli markets, and supermarkets, were caught selling to youth and young adults.

Why I say young adults is because it is illegal for anyone under the age of 21 to purchase this. And out of all of them, the tobacco and smoke shops in particular had a higher rate of violations, sitting at almost 30% of them being caught selling to young people and minors.

These bad actors are taking advantage of the fact that we define them all as an umbrella, all the things that I mentioned. And so my bill is looking to do a couple of things. And one of them is to pull out the tobacco and smoke shop and have it be defined on its own so it's not coupled in with the deli markets, the supermarkets, and the gas station.

And what would be good with the statewide definition of tobacco retailers is to be able to place additional regulations on their operations to safeguard our communities. Because right now, unfortunately, some of these shops are located, like I mentioned, to these youth sensitive locations.

And according to the American Lung Association, the density of the tobacco retailers, particularly around schools, has been associated with increased smoking rates. And one third of illegal tobacco sales take place within 1,000 feet of schools.

So enter SB 1314, the Youth Over Smoke Act, looking to address this crisis by doing the following. Like I mentioned, create a statewide level definition for smoke shops whose primary business is the sale of tobacco products.

They must adhere to the requirements in this bill. And those requirements include imposing a default sensitive use buffer of 600 feet away from a sensitive receptor, like a school or daycare center, beginning July 1, 2027.

It will prohibit the same smoke shops from possessing or selling nitrous oxide or nitrous oxide paraphernalia. Because currently right now, it is you can purchase them, but the moment you step outside and you're caught within possession, law enforcement can arrest you. There's a discrepancy in how we're treating this.

It would now with the amendment, it no longer authorizes CDPH, but currently authorizes CDTFA to develop additional regulations for the operation of smoke shops because I am taking the committee amendments. And it preserves, of course, local control by allowing the local governments to develop even more stringent.

They can go below 600, but they can increase that to up to 1000 or whatever they feel is best. And aligns the revenues out of the violation to go into a fund that currently exists right now, which is the Stop Tobacco Access to Kids Enforcement Act, and there's civil enforcement mechanisms.

Lastly, I want to flag that there were continuing conversations from the previous committee, and I know that none of those are being absorbed here because it doesn't fall under the jurisdiction. But I'm still committed to taking those amendments in the, in Appropriations before it hits the Senate floor. Madam Chair, I'd like to now turn over to my witness, the council member.

Thank you. You will have a total of five minutes for your presentation.

Thank you very much. Thank you, Chair and Senators. Eric Guerra, council member for the City of Sacramento, here in strong support of SB 1314, the Youth Over Smoke Act. Cities across California are increasingly struggling to manage the rapid proliferation of smoke shops.

Sacramento is no different. Many of them now selling whippets, and local enforcement capacity is limited. In Sacramento, a 500,000 plus city, roughly only 5-10 code officers are responsible for overseeing hundreds of smoke shops and ensuring compliance with both state and local ordinances on top of all of their responsibilities.

This is why cities need your, need the state's help now. SB 1314 is good land use policy and it ensures that commercial spaces have a higher and better use within our neighborhoods, particularly in front of our schools.

In my district, a smoke shop once proposed opening directly in front of Tahoe Elementary. But through local policy, that space ultimately became a business that provided great businesses of greater value for the community.

For some, a very popular brunch spot spot, you may know, Bacon and Butter, and also an autism awareness center. Better than having a smoke shop right in front of our, of our schools. SB 1314 strives to ensure commercial spaces near our schools are not consumed by smoke shops and those spaces are available for a business of higher and better use.

Some childcare centers and some schools are near city and county borders. And this is why it's important that this state law pass so we can have a statewide standard. Sacramento has a thousand foot restriction, more than the 600. But if it's right across the county line, then that restriction doesn't comply.

A statewide standard like SB 1314, like a buffer, operating hours, restrictions on nitrous oxide, these whippets will help cities protect youth and support responsible retail practice and create consistency across California. This is why our cities, this is why cities need your help now. And for this reason, I respectfully urge your support of SB 1314.

Thank you. If there's anyone else in the audience that would like to register your support, please come to the microphone. State your name, your organization, and your position.

Yes. Good afternoon, Madam Chair and Members. Amy Jenkins here on behalf of the California Cannabis Operators Association as well as the Orange County Board of Supervisors in strong support. Thank you.

Serena Scott on behalf of the League of California Cities in support. Thank you.

Good afternoon. Angela Blanchard on behalf of the American Academy of Pediatrics California Chapter in strong support. Thank you.

Brendan McCarthy with CSAC in support. Apologies for not getting our letter in time for the committee, but we are in support. Thank you.

Ryan Sherman with the California Narcotic Officers Association in support. Thanks.

Gilbert Lara here on behalf of the council member's district, constituent in support.

Thank you. Seeing no one else who's coming forward. If there's anyone here who would like to speak and lead opposition on this bill, this is your time to come forward. Seeing no one. If anyone would like to register their opposition, this is your time to come forward. State your name, your organization, and your position. Seeing no one. I will now bring it back to the committee. Senator Caballero.

Senator Menjivar, thank you for bringing this forward. This makes a lot of sense to me. I have a question, and I don't, we're in the wrong committee kind of to... But I believe that alcohol outlets have a restriction from these sensitive sites.

And I'm just wondering if somebody could look up what... The reason where my thought is going is if we line it up with the alcohol outlets, then we have a map that shows where the sensitive sites are and the ABC does the enforcement on these.

And it may be able to, there's a synergy in using the same distance so that we're looking at the same things. Alcohol and tobacco have no business around daycare centers and schools and other sensitive sites where children are likely to be located. I'm assuming parks, that kind of thing.

Yeah. I don't. I don't know what all falls under that. Mine is just on schools and day daycare centers. I would have to check what extended list they are allowed to be away from.

They use. Yeah. I just think this is a really good bill. And a big part of the of the challenge is that a lot of these, the reason that the alcohol distances were set up in the first place is they were popping up in over concentrated areas around poor neighborhoods.

And so the bill, the restrictions have been adopted for a really long time. We may just wanna look at that and see if we can do an overlay at some other date. I'm gonna support your bill. I think it's a really good idea. But it just seems to me that we're battling them kind of one thing at a time. And if we put them all together, we may, it may make, more logical sense.

That's a great point. You know, we at least for the 600 buffer, Senator, we aligned it to the cannabis kind of buffer. So we wanted to make it as standard as possible. But it's the first time someone's pointed that out to me, so we'll take it back.

Thank you. Senator Durazo.

Just, I will be supporting as well. I think it's correct. We're dealing also with vaping, as something that was deliberately targeting young people with the flavors and all of that. I'm curious. This isn't anything that's exclusive to children. Right?

I mean, adults. So do you have any information as to is it more of the kids, a higher percentage of kids? Is it more adults? I mean, something about the usage so that we can figure out prevent, how do you prevent the kids? How do you prevent the adults from using this?

Yeah. So we've have reports on deaths. Even today, I think LA Times had an opinion piece on this very very topic. I think there's about four bills going through the legislature on this, so there's an interest on it. But we weren't able to desegregate the percentage of who were the deaths for the kids versus the adults.

So I had asked for that information, so we've been looking for it. It just we haven't found desegregated information. What we have seen is just a surge of youth utilizing vaping. And what law enforcement has seen also is a lot of DUIs where people have been are passed out after utilizing nitrous oxide. So that could be young adults as well.

I'll just mention my teenage granddaughter says it's common to go into the bathroom and...

Yes. They're seeing that constantly. So if we make nitrous oxide illegal to for them to sell, that could help deter it. Obviously, it's hard for us to say anything we do will always stop whatever we're looking to fix, but at least it helps the situation.

Thank you. Senator Rubio.

Thank you. I really appreciate this though. Since I've been here in the legislature, I've have numerous bills on just trying to tackle smoking in our youth. You know, as a teacher, I always share how, you know, our kids find creative ways of hiding what they smoke.

And I just remember passing bills on vaping, to tackling marketing strategies to engage our our youth, to these devices that are meant to conceal. In fact, you know, I tried an educational program to teach parents because, you know, we had pens, we had markers, staplers, things that are ordinary devices.

And every time we tackle one issue, three more come up. And this one is an issue that my fellow teachers will call and share. It's becoming a common occurrence just like all the other things like vaping. So I'm really encouraged by this.

And I do think it's critically important, especially because they're always seeking to be in proximity of these schools or vulnerable areas where they find our youths that are not accompanied by adults or they walk by.

And so I think it's important. And I also have many bills mechanism on how to enforce the violations and have stricter penalties. But I'd love to be a co-author and just, you know, have a conversation with you to see how we can, you know, go a little further on it.

I know this is a place to amend, but, you know, just talk about ideas because it's an important issue and it's not going away. It just keeps getting worse. So I appreciate you bringing it up.

Thank you.

Thanks, Senator.

Thank you. Senator Valladares.

Thank you. One, I can appreciate what the author is trying to accomplish here, as a mom of of a daughter, who I hope, you know, never is attracted to smoking or vaping, any of it. I just have concerns that we've done so many things to try and reduce the usage and it's not happening. And I'm not gonna get in into all of that right now.

Because I'm trying to kinda understand the reasoning or the thought process behind this aspect of the bill. Which would permit a smoke shop only to engage in the retail sale of tobacco products directly to the public between the hours of 6AM and 10PM, which seem like those are kid hours. Right? Like, so I'm not understanding, you know, where this concept from the bill came from, if you could explain.

We matched it to the operating hours that are imposed right now on cannabis shops. Those are the same exact hours. That's where it came from.

Thank you.

But, Senator, if it was up to me, I would rework it to say you cannot be open during while kids are walking to school or walking out. But that be too much of a Swiss cheese kind of situation.

Seeing no further comments. Senator, really want to thank you for bringing this bill forward. You know, it seems like we're always having to figure out new ways to protect our children as these people in these various industries find new creative ways to target our children. They know that if they get them when they're young, they can get them addicted and have a customer for life.

And so I really appreciate you bringing this forward and the sponsors for bringing this forward and educating all of us on this issue that we may or may not have been aware of ourselves. And so would also love to be a co-author and would...

I'll take you.

You know, you may close at this point.

Thank you so much. You're right. We keep coming to, we keep having to come back. It's because they're finding new ways. I think we're gonna have to continue to come back and do new regulations after new regulations because one day they're gonna be selling bananas that you can just inhale, and then that's gonna get you high.

I just, they're finding new ways to get our kids. And Senator Caballero, they are in black and brown communities. My district is saturated with these. I don't have parks, but I have smoke shops in my district.

And if that's what a kid is consistently being exposed to, it's eventually, it will become like a self fulfilling prophecy of, like, if you say that happened to them and you put it in front of them, it's gonna happen.

So we will continue to bring back legislation that will be creative as well and meet the moment to continue to protect our kids. And this is just one step in the right direction. With that, respectfully asking for an aye vote.

Thank you. I will entertain a motion. Moved by Senator Rubio. The motion is do pass as amended and re-refer to the Committee on Appropriations. Assistant, please call the roll.

[Roll Call]

That bill is 6-0 and we will place it on call. We will now move back on file to file number 8, SB 1309 by Senator Rubio. You may begin when you are ready.

Thank you madam chair and members of the committee. I want to note, I'm accepting the committee amendments noted in the analysis. I wanna thank you for the opportunity to present SB 1309, the Stop Lung Cancer Early Act, which will save lives by eliminating out of pocket expenses for medically appropriate lung cancer screenings. This bill makes it a really critical change, which I believe will save lives. It will remove financial barriers preventing patients from accessing life saving follow-up care.

A lot of the times, we know that access is key and studies show that people don't get preventative care because of cost barriers. And so, preventative care is the best way, again, to stop unhealthy, progressive, ailments. And in this case, it's lung cancer. We also see the success through the life saved already when we tackle decreasing the cost of screening for breast cancer, cervical cancer, and colorectal cancer. So we wanna do the same thing for lung cancer.

Lung cancer is California's deadliest cancer, killing over ten thousand Californians a year. However, our screening rates are critically low, under ten percent to be exact, whereas other cancers are above seventy percent, and that's due to access. So the costs are the main reason why people avoid, getting, those necessary screening. So these barriers also disproportionately impact our vulnerable communities. We know that veterans are having a hard time, getting follow-up screenings, as well as disproportionately it impacts people of color.

So we wanna make sure that we do, what we can to encourage that follow-up but follow-up care. So also, I wanted to note some some information. Less than a quarter of lung cancer cases are diagnosed at stage one when survival rates is the highest. Also, around half are diagnosed at stage four, and that's when the rates are I'm sorry, when the the rate of success is the lowest.

But so by removing the barriers, we increase early detection, we improve survival rates, and reduce lung term I'm sorry, long term health care costs associated with late stage cancer treatments.

So this bill, SB 139, is very targeted. It's evidence based, and it only updates an existing policy that we currently have. One that aligns lung cancer screening with other already, other covers, covered already and, that we've done in the past. And with me today to speak on this very important bill is Laura Rose, Oncology Nurse Practitioner of Providence Saint John's Health Center. We also have Chris Draft, former NFL Linebacker and Lung Cancer Advocate after the loss of his wife.

So if I may, sure, I'll turn it over to my guest.

Thank you. You will have a combined total of five minutes for your presentation.

Good afternoon, madam chair and committee members. My name is Laura LaRose and, as the center said I'm an oncology nurse practitioner. I have over sixteen years of experience caring for cancer patients. I'm also a volunteer with the American Cancer Society Cancer Action Network. I'm here in strong support of Senate Bill 1309.

In my practice, I care for patients from diagnosis through treatment, up until end of life care. One of the most concerning patterns that I see is delayed diagnosis of lung cancer. This isn't always just because screening isn't happening, but because patients can't afford the follow-up after an abnormal result. While screening may be covered, patients often face out of pocket costs for essential next steps like diagnostic imaging, biopsies, and specialist visits. From a clinical perspective, these are not optional.

They are medically necessary to confirm or rule out cancer. Lung cancer is an aggressive disease where timing matters. Delays and follow-up can mean the difference between early stage treatable cancers and advanced disease with far fewer options and significantly worse outcomes. I also see the burden fall disproportionately on patients already facing barriers to care. Cost sharing creates a real obstacle, especially for lower income patients, leading many to delay or forego care altogether.

SB 139 closes this gap. It ensures that when we screen for lung cancer, patients can actually complete the process of care. As a clinician, ordering the right test only matters if my patients can access it. This bill helps turn clinical recommendations into real care. I urge you to support on SB 13 o nine.

Thank you.

Thank you. Good afternoon. Chair, whoever Pearson and members, sorry. My name is Chris Draft and I'm here to speak on SB 1309. I'm a former NFL player, but not just an NFL player.

I play for the forty niners and for the Rams and I grew up in Anaheim, California. Thank you. And graduated from Stanford University. So I am extremely biased with California. But, you know, more importantly, I'm I'm here as a husband who lost his, wife, Keisha, to lung cancer.

She was diagnosed at 37 years old, no history of smoking. And passed a year later, Stage four lung cancer, 37 years old, a year later passed away. And I carry that memory to everything that I do. But I also have another connection. I had other connections as to my my uncle.

My uncle, Eugene Polk, army vet, that as soon as he went to the army, was introduced to smoking. And that became a part of his his lifestyle that where he was diagnosed with lung cancer and ended up passing in 2002. And so he's somebody that could benefit could benefit from lung cancer screening and so many people ask me, they say, would lung cancer screening benefit your wife? And so, unfortunately, she was diagnosed late stage, and it wouldn't have based on the criteria.

But it would save so many lives, my uncle being one of those and so many other veterans and so many other people that we know have been taken advantage of by the tobacco industry.

You know, what we've learned through my experience to working with families across the country is early detection, it it works. We know it. Alright? We see it in breast cancer. We see it in colon cancer.

It's a game changer. We find it early. It not only changes the cost, but it changes the lives of the people. It changes that they don't have to go to a cancer center very often or they have to go only for a little bit. But their quality of life is transformative.

So right now, less than twenty percent or in California, less than ten percent of eligible for lung cancer screening actually get screened. And even when people do take that step, step, cost could become a barrier to follow-up. Yeah. We know that. It's it's unfortunate.

Because again, they if we can find it early, it can be transformative. I've seen people do everything right, get screened, but then face unexpected out of out of pocket costs for follow-up tests. And at that moment, some delay care or walk away entirely. Too often, we don't talk about that. We don't we talk about how important it is to get diagnosed early, but we don't talk about the barriers that make it where somebody might just give up and not do it.

Cancer is absolutely serious, but there are the financial toxicity is serious too. So that's where we lose the opportunity to catch cancer early. So SB 1309 helps close the gap by ensuring that individuals who qualify for screening can also access to medically necessary follow-up care without cost barriers. It's about making sure early detection actually works and giving families a real chance at better outcomes and more time together.

So on behalf of families like mine, I respectfully ask for your aye vote for SB 1309.

Thank you.

Thank you. If there's anyone else in the audience that would like to register their support, please come to the microphone. State your name, your organization and your position only. Thank you.

Jennifer Snyder on behalf of City of Hope and the California Life Sciences in support. Thank you.

Thank you.

Sarah Nocito on behalf of the California chronic care coalition in support. Thank you.

Christine Smith, Health Access California in support.

McKay Carney on behalf of Cedars Sinai in support. Thank you.

Thank you.

Jennifer Tannehill with Aaron Reed and Associates on behalf of the California Society for Respiratory Care representing Respiratory Therapists throughout the state in support.

Thank you.

Gilbert Lara here on behalf of Biocom in support.

Thank you.

Thank you.

EJ Aguayo on behalf of the California Academy of Family Physicians in support. Thank you.

Good hap good afternoon. I'm Marie Kennedy, volunteer advocate with the American Cancer Society Cancer Action Network and very much in support. Thank you.

Thank you.

Megan Murray on behalf of Breathe Southern California in strong support.

Thank you.

Kevin Guzman with the California Medical Association in support.

Thank you.

Cher Gonzalez. On behalf of my clients, the Association of Northern California Oncologists and the Medical Oncology Association of Southern California. Apologies for no letter. We are in support. My board just has to formally adopt it next week.

The letter will be forthcoming. Thank you.

Thank you.

Kenneth Wilkerson on behalf of the American Cancer Society Cancer Action Network, proud cosponsors in support.

Thank you.

Kesa Bruce with the American Lung Association, proud cosponsor in support. Thank you.

Seeing no further individuals that would like to come forward to register their support. If there is anyone that would like to speak in lead opposition, this is your time to come forward to the table.

Are you lead opposition. Okay. You can have a seat.

Olga Shelest, on behalf of the California Association of Health Plans, in respectful opposition to SB 1309. We share the author’s commitment to early detection and timely follow-up care for lung cancer. Importantly, preventive screening is already covered without cost-sharing, ensuring access to early detection.

Where we struggle with SB 1309 is not the goal, but the elimination of cost-sharing for follow-up care. Costs don’t disappear—they get shifted to premiums and are paid by everyone: families, small businesses, and public purchasers. We also want to note that CHBRP estimates this would increase premiums by over $27 million annually, at a time when health care affordability is already one of the biggest pressures Californians face.

So we want to work with the author and the committee on solutions to help patients most without increasing premiums for everyone.

And for this reason, we oppose, the bill. Thank you.

Thank you. If you could come and sit at the table in case anyone has any questions for you.

Good afternoon. Sorry, chair. Good afternoon, chair and members. Matt Aiken on behalf of the Association of California Life and Health Insurance Companies. Also respectfully in opposition to the bill and would just like to align my comments with my colleague at CAP. Thank you.

Thank you. If there's anyone else that would like to register in opposition, if you can come to the microphone, state your name, your organization, and your position. Seeing no others, we'll bring it back to the committee. Senator Caballero.

Thank you very much, madam chair. If I could ask of the opposition that $27,000,000 annually equates to what amount per, rate payer for lack of a better amount.

Per member. Yes.

Yeah. I believe that was in noted in the analysis. Yeah. An additional 0.06 to 31¢ per member per month.

Okay. And and that includes everyone that's covered by insurance. The contract insurance.

I believe that's the range across across the markets. Yes. Great.

Thank you very much. I wanna thank you for bringing this bill and also thank you both for your testimony here. Quite frankly, was shocked to find out that if you're diagnosed with lung disease that the follow-up doesn't get covered. Which I mean, I think there's expectations from myself. Have the expectation that if something's gonna be discovered, whatever needs to be done is gonna be something that, is gonna be covered.

And the amount just doesn't seem to be that cost prohibitive. I mean, this is part of the reason that we're moving slowly to single payer healthcare because the bottom line is everything needs to get shared so that it it's minute after a while. If you if you're cutting out some of the middle people that are taking money but not rendering any services. So I know I'm on a soap box.

I wanted to, just say that I think this is a really important bill and the sooner we get things diagnosed and the sooner we get people into treatment, the better off we're gonna be.

And I've seen that the incidence of lung cancer is surging among young people. And we've got to figure out why that's happening, and how to how to prevent it. Especially when in a situation where there's the individual is not a smoker. So sorry for your loss and, thank you for being an advocate for a resolution. Thank you, madam chair.

Thank you. Senator Durazo.

I also I wanna, hate to say this, repeat what Senator Caballero said. This is a really great, great bill. And thank you very much, Senator, for bringing this forward. I also was ignorant of the fact that once you're diagnosed with an illness like that, that you there wouldn't be follow-up. It just there's no doesn't make any sense.

And not only the lives as, your loss, the lives of people, but more importantly, all the suffering that takes place and all the stress, all the horrible things that somebody must go through when they, so anyway, it needs to stay supported. I also, though, think we have to think about cost every time something like this comes up because it also falls on on the shoulders of working people. Working people, there are more and more poverty, working poor, who just can't handle it.

Spreading it could be 30¢, per person, but a lot of things get added on and added on and added on. So I hope there's a way of addressing this without just saying that's not our problem, you know.

It is our, collective problem as well. But I will be supporting it. Thank you.

Thank you. Senator Valladares.

Thank you. I'm gonna be supporting this bill and I often share my mom's own, diagnosis with pancreatic cancer. And, you know, she was diagnosed on accident in 2012 and she was in remission for nearly six years and she went for her follow-up, every every year first every six months and every year. And come to find out that especially with pancreatic cancer, there's just no there's no meaningful early detection even when you're, you know, you know it exists and you're in remission.

So I am curious to know I have two questions.

One, when it comes to follow-up and screening for diagnostic services, what is covered. In my mom's case, and I know it's not lung cancer, you know, the only way they would have caught it, again, would have been if they were doing PET scans, and they weren't they weren't doing PET scans. They were doing, you know, blood work. So is it pretty much any follow-up or diagnostic that the doctor would prescribe would be covered, to maybe the doctor.

Nurse practitioner. So the follow-up tests might include PET scans like you mentioned, follow-up CT scans, biopsies, things like that. So those would be the follow-up for an abnormal lung screening.

But then the subsequent exams wouldn't be screening tests anymore. It would be a diagnostic work up and that's where the coughs cost sharing kicks in for patients.

Okay. So I think, the issue is not so much do health plans cover the follow-up. It's the cost sharing issue or the co-pays. And so what this bill would do is it would eliminate the requirement for cost sharing because we know that for many people that alone is prohibitive.

Correct. And just some procedures are more expensive than others. So that's was gonna be part of the premise of my question, but that's okay. Is there any data that exists to show, the cost of care for someone who is diagnosed after having been in remission, diagnosed early, you know, stage one or stage two versus what's spent when it's caught when it's caught, you know, stage four.

Well, I have some numbers. I'm not sure, if that this answers your your question. But, basically, what patients have to pay after, you know, according to what I have here from the Schuberth estimates that a subset of patients will receive earlier stage diagnosis because they don't go get care because of the bill and they avoid treatment. The approximate cost is a 149,000 that they have to sometimes pay out of pocket. And so that just that alone discourages them from coming forward.

And that's just the cost of diagnosis and and some services. But I'm just looking at it from the perspective of if you can catch lung cancer or any cancer early and just like anything, you can intervene early. You're gonna find a savings versus if you're caring for it at stage four when it's everything under the sun and you're, you know, every right to try all of it.

I don't know if the health plans have any data have collected any data on what the cost of treating someone that you diagnose early versus someone you diagnose that's diagnosed later.

Thank you, Senator. We don't have data. I don't have it on me at this point but, would be happy to see what we can find out from our individual members and Thank you. Report back to you.

I mean, I think it's really important if we're looking at whether or not this is gonna be I mean, it's worth the bill. Whether or not this is gonna actually be more expensive or if we're gonna save money or if it's a wash. So that's all. Thank you.

If I could say, like, as a clinician, when someone is diagnosed with early stage lung cancer, it is often treated with a single surgery or a course of radiation. Whereas, if someone is diagnosed late stage, and we're making a lot of advancements in late stage lung cancer, but it is a lifelong treatment of very expensive medications. Like tens of thousands of dollars a month for the rest of that person's lives. And the good news is people are living longer.

But that's a huge cost burden to the health system.

And so if I'm sure when they run the numbers that it's gonna add up. But a single surgery is probably more affordable than a decade of very expensive medication.

Okay. Seeing no further comments or conversation, Senator, I wanna thank you for bringing this bill forward. I wanna thank you for coming and testifying and sharing your very personal story, being very vulnerable in in public with all of us that are here and those who are watching. You know, my condolences to you and your family that I'm so young. And I like I said earlier, we attribute lung cancer a lot to tobacco but there are other causes of lung cancer.

And those individuals are often much younger and just kind of out of the blue and completely unexpected. So my condolences to you. You know, with this bill, we are focusing on, follow-up for screening modalities. And we talk a lot about prevention, prevention, prevention which I have said over and over and over again. That if we focus more on the preventative aspect for anything, then that will actually lower the cost of healthcare in the long run. Because we will not have to pay for hospitalizations.

We won't have to pay for surgeries. We won't to pay for very, very expensive medications. And for some reason, we have a difficult time focusing more on the preventative side and understanding that that will cost less in the end. But not only cost less to the healthcare system but also quality of life for that particular individual. The ability for them to be able to contribute to their communities because they can continue to work.

The impact that they'll have on their families is so significant. When we focus more on what we can do upfront and not wait until someone has the actual condition and we're now trying to treat that. So this is a great bill I think it kind of goes in alignment with what we saw earlier with, Senator Archuleta and, you know, talking about informing people about screening.

So if we're gonna say, hey, we need to screen more for lung cancer, Then if something is found on that screening test, then we shouldn't say, okay, now you must pay something in order to go ahead and get the further diagnostic test that you need to see if you truly have lung cancer, or or anything else.

So thank you so much for bringing this bill forward. You may close.

Thank you. And I wanna just highlight. Thank you madam chair for, for what you just stated. I wanna highlight that very important point. Right?

We are talking about pennies. It just, you know, it baffles me in terms of, you know, the cost at the tail end and we just heard the nurse practitioner talk about a lifetime of medication treatment, whatever that may mean for that family. But, when you're in this business long enough, you hear stories. I mean, I've heard it all from, family members discovering that they need treatment, but their family's already financially stressed.

So they don't even tell the family because now they're gonna have to choose whether it's a college tuition or get care.

And so people are not getting the care they need. But another important point that I like to make, because I like to educate our youth, is, you know, I always ask, you know, about, our youth. The other day in this committee, we had Alzheimer's. And I always ask, give me the the diagnosis of the youngest individual. Right.

And I think it was 18 and I was shocked because we always think of Alzheimer's, cancer, and all these issues as an older person's disease. But when I heard 18 Alzheimer's and that's the youngest diagnosed, something's happening clearly. So I do think that we're seeing a spike on younger younger people. I know a 25 year old, young woman who died of breast cancer. And again, that was not typical.

But out of pocket cost cannot be the reason why they don't get care. And I think that, you know, you just stated that we pay at the front end, but at the end, we save money because not only are we saving the trauma to the family, we're saving cost to the health plans and, and I think it just makes for a better society. With that, I respectfully ask for an aye vote. Thank you.

Thank you. At this time, I will entertain a motion.Moved by, Senator Valladares. The motion is do pass as amended and re-refer to the committee on appropriations.

Assistant, please call the roll.

Senator Weber Pierson, aye. Weber Pierson, aye. Valladares, aye. Valladares, aye. Caballero, aye. Caballero, aye. Durazo, aye. Durazo, aye. Gonzalez, aye. Gonzalez, aye. Grove. Menjivar. Padilla. Perez. Rubio, aye. Rubio, aye. Smallwood-Cuevas, aye. Smallwood-Cuevas, aye.

Thank you.

7 - 0. We'll put that bill on call.

Now moving to file item number 11, SB 1199. Senator Weber Pierson, you are recognized when you're ready.

Thank you. Good afternoon Madam Vice Chair and Members of the committee. I am here to present SB 1199 which would ban the use of co pay accumulators in California. Joining 20 other states in banning these. I will be accepting the committee amendments today.

Co pay accumulators are harmful practice increasingly used by health care insurance. Insurers that can leave patients with significant out of pocket cost. Co pay accumulators allow insurance and pharmacy benefit managers to pocket patient assistance intended to help those patients meet their shared cost instead of counting those payments towards the enrollees annual out of pocket limit.

For individuals living with chronic or terminal illnesses, out of pocket cost can quickly add up when having to pay the plans maximum out of year after year, making it difficult to afford essential medications and treatments. This is especially true for patients diagnosed with conditions that require medications to manage it.

Over the past decade, insurers have increasingly shifted the cost share of specialty medications to patients by increasing deductibles and charging coinsurance for specialty medications which allows California regulated plans to avoid California's 250 monthly co pay cap for prescription drugs. As a result, many patients must rely on financial assistance from third parties to afford their vital medications even though they do have health care coverage.

However, insurers are increasingly undermining this assistance by not counting the amount of money covered by manufacturer or charity co pay assistance programs towards the enrollees annual deductible and out of pocket limit. Instead, the co pay assistance funds are accepted by the health plans or PBMs, but not counted towards the patient's cost sharing obligation. Banning co pay accumulators can also help avoid situations in which individuals may forego necessary treatments due to cost concerns.

By helping patients maintain adherence to their medications, this legislation can lead to better outcomes for patients and lower long term cost for our health care system by reducing costly ER room visits and hospitalizations. Additionally, these co pay assistance programs help address health inequities by making necessary medications available to under insured and under resourced patients who otherwise would have to fuse between food and medicine. It is imperative that we take action to ensure that all patients have access to the care they need without facing financial obstacles.

To date, 20 states, both red and blue, have banned their use, and California should be added to the list. Thank you, and I respectfully ask for an aye vote.

With me today in support is Miguel Basidas representing the sponsor, the Department of Insurance, and, Jerica Code? Jerica.

Jerica. I'm sorry. Volunteer and patient advocate with the Arthritis Foundation. Thank you.

Thank you. You're both, recognized for five minute minutes combined.

Good afternoon, Vice Chair and Committee Members. My name is Miguel Bastidas, chief deputy legislative director for the California Department of Insurance. Here under the leadership of insurance commissioner Ricardo Lara. As a proud sponsor of SB 1199, commissioner Lara would like to thank the Chair, Senator Weber Pierson, for her leadership in authoring this critical patient protection and affordability measure. SB 1199 simply fixes an accounting issue.

If cost sharing is paid by a consumer or on their behalf by anyone to obtain their medications, it should count towards their maximum out of pocket limit, also known as MOOP. Existing federal law requires all cost sharing to count towards the MOOP. This includes payment payments made by a consumer, but also payments made on their behalf. In California, existing law bans manufacturer assistance on cost sharing for prescription drugs except in specific circumstances.

SB 1199 does not change the underlying policy of the state or Federal Government regarding the use of coupons.

Instead, 1199, SB 1199 would homogenize existing federal requirements related to counting cost sharing with California's existing public policy related to manufacturer coupons. Emerging current state and federal requirements, SB 1199 encourages carriers and PBMs or pharmacy benefit managers to put lower cost generics on their formularies, which in turn helps steer patients away from higher cost brands, brand name drugs, and discourages their overuse.

At the same time, SB 1199 ensures that patients are able to have their cost sharing count towards their MOOP when legal in California. Patients shouldn't have to rely upon coupons to afford life saving or maintaining prescriptions. But but when they are paying for insurance, they should be able to rely upon the full protection of their insurance policy when cost sharing has been paid by the patient or anyone else.

At least 26 other states, as well as DC and Puerto Rico, have enacted laws codifying or exceeding federal requirements. As one of the regulators of the private health insurance market in California, it is critical that the department has the tools to enforce both state and federal law. SB 1199 simply codifies what is already good, federal law. On behalf of insurance commissioner Ricardo Lara, I respectfully ask for your vote.

And with me today also is assistant chief counsel for the department and the Health Equity and Access Office to answer any technical questions.

Thank you.

Good afternoon. Oh, sorry. Get that on. Good afternoon, Vice Chair and Members of the Committee. My name is Jerica Code and I'm a longtime patient advocate with the Arthritis Foundation.

My involvement with the foundation began nearly twenty years ago when my daughter, Macy, was diagnosed with juvenile arthritis. When I thought of arthritis, I thought of an older person with swollen fingers and slowed movement. But in October 2008, my daughter was diagnosed at just 18 old. I come today to ask for support of SB 1199. This bill would end the use of co pay accumulators.

This patient focused bill aims to ensure that all payments made by or on behalf of the patient are applied

towards deductibles and out of pocket maximums. I first learned about accumulators a few years ago when I called the specialty pharmacy to refill Macy's biologic medication. This should have been a simple routine phone call that took about five minutes. However, it lasted about forty minutes and resulted in weeks of other calls and follow-up. What should have happened is that the co pay of nearly $1,600 should have been covered by our co pay assistance card, leaving me with just a $5 cost.

In that call, I learned that the funds from the card had been exhausted. After many calls with our health plans, specialty pharmacy, drug manufacturer, and our doctor's office, I learned that all year the funds from the co pay card had not been applied to our out of pocket maximums. Typically, she would have met this amount in the spring and then would be covered at a 100% for the rest of the year.

I was now faced with the problem of coming up with $1,600 for the co pay to avoid a delay in treatment. I felt overwhelmed figuring out such a big financial decision.

There was a lack of transparency from the insurance provider for me to understand what caused the change. Ultimately, we sacrificed to cover this expense while I continued to fight for coverage. In addition to the obvious financial costs, there are many invisible costs that have had a profound effect on my family when it comes to her treatment. Monthly appointments at a specialist three hours away, weekly physical therapy, monthly infusions, trips to the pharmacy, hours spent on the phone with insurance.

Not to mention the time spent just comforting her when she was in pain.

This all led me to leaving a successful career that I loved, which meant loss of income and loss of contributing to retirement for fifteen years. My husband often feels tied to his job because we need insurance that has her drugs on their formulary. Plus the social and emotional impacts, disease progression, and the list goes on. These biologic drugs are life changing. But due to issues with co pays, they can be cost prohibitive for many patients.

For Macy, without these medications, she lived in constant pain, struggled to make it through the school day, and often felt sidelined from her own life. She's also a patient advocate and shares her own story of invisible costs. She tells a story about how much she loves school, particularly science. In third grade, she was so excited because her class was going to use microscopes for the first time.

You put the pain in her her legs was too much and she went home early before she had the chance.

That same little third grader is now finishing her first year of college, and she still loves science. In fact, she's a double major in biology and public health with dreams of going to medical school. She's also a division one college athlete and a patient advocate. And all of this is possible because of timely and affordable access to treatment. SB 1199 would directly support patients like Macy by removing the barrier of co pay accumulators.

I urge you to vote for patients by voting yes on SB 1199. Thank you.

We'll now move to anyone else in the room that would like to express your support. Please state your name, your organization and your position only.

Tim Madden representing the California Chapter of the American College of Emergency Physicians, the California Chapter of the American College of Cardiology, and the California Rheumatology Alliance all in support.

Ej Aguayo, on behalf of the California Academy of Family Physicians in support. Thank you.

Lynn Kinst on behalf of the Bleeding Disorders Council of California and the California Rare Disease Access Coalition in strong support.

Missy Johnson on behalf of the Cystic Fibrosis Foundation in support.

Ryan Spencer on behalf of the California Podiatric Medical Association and the Crohn's and Colitis Foundation in support.

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

Kathy Mossberg on behalf of San Francisco AIDS Foundation in support.

Sarah Macedo on behalf of the California Chronic Care Coalition in support.

Craig Pulsar on behalf of Equality California in support.

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

Cher Gonzalez on behalf of the Association of Northern California Oncologists and the Medical Oncology Association of Southern California in support.

Kevin Guzman with the California Medical Association in support.

Gilbert Laurie here on behalf of BioCom in support.

Michelle Johnstone with the National Multiple Sclerosis Society in support. Thank you.

Thank you. We'll now move to any key witnesses here in opposition. Thank you. And you're both recognized for a combined five minutes.

Madam Chair and Member, Stephanie Watkins on behalf of the Association of California Life and Health Insurance, regrettably here in opposition to SB 1199. I'd like to thank the Chair for her thoughtful engagement on this issue as well as her staff and sponsors. We had a sincerely, productive conversation last week and we appreciate all the time that they spent with us as we worked through what can otherwise be a really complicated issue.

While we share the goal of making prescription drugs more affordable, we have serious concerns about codifying the existing federal rule related to copay accumulators into statute. Would require health plans and insurers to count manufacture copay coupons and other third party payments towards a member's deductible and annual out of pocket max.

Currently, pharmaceutical companies often offer coupons to privately insured patients in order to provide discounts on brand name drugs even when lower cost generic alternatives are available. While these coupons are often lower or eliminate the patient's co pays in the short term and then long term, they could lead to uncertainty about a patient's out of pocket cost for month to month since pharmaceutical companies can change their coupon programs and patient eligibility roles for those programs at any time.

We further are concerned that these coupons enable drug manufacturers to maintain high list prices and drive up costs for all patients through higher insurance premiums. Drug companies often keep these drug prices high by setting their own list prices and then offering co pay coupons in order to help some patients afford those high prices. Companies also use drug coupons to increase drug sales for a particular brand name drug and to steer patients away from lower cost generics.

The goal here is to establish brand name loyalty over lower cost options. To that end, our position is underscored by a recent bipartisan effort on the federal level to ask the governmental accountability office to assess whether manufactured copay coupons steer patients toward higher cross brand name drugs. This oversight is intended to clarify how coupon programs affect utilization and total spending over time.

Having said that, we would caution the legislature at this time from codifying the standard as it appears this issue will likely be included on the spring calendar to be reviewed. At this time given the potential cost and broader implications of this policy, we think it warrants the legislature slowing down the process in order to give us time to evaluate the impact of policy on access and affordability.

For those reasons we are opposed to the bill, we understand and appreciate if it moves forward today. We'd like to continue our engagement on the issue. Thank you.

Madam Chair, Members, Sean Wenger here on behalf of America's Health Insurance Plans. We're the National Trade Association for health plans. In the interest of time, I just aligned my comments with ACLIC and, certainly agree that this is really fluid at the national level and believe that this bill is a little bit premature, related to that. But, should the the bill move forward, you know, we have been active in other states that we've continued to advocate for, particular amendments to this type of legislation.

One would be requiring manufacturers to provide financial assistance to the patients for the entire plan year and notifying the patient of their terms and conditions in advance.

We would also advocate for requiring manufacturers to annually annually report on the amount that they spend on financial assistance and also require manufacturers to inform health plans when they are providing a coupon or other type of financial assistance to an, enrollee of that plan. A lot of times, we're left out of the loop. It's directly between the the patient and the pharmacy and the drug company. And so, we feel like more transparency there would be warranted and, look forward to further discussions on all of that.

Thank you. We'll now move to the committee room. Is there anyone else here that would like to express their opposition? Please come forward, state your name, organization position. Seeing none, we'll move to the committee.

Senator Caballero.

I appreciate what you're trying to do. I was impressed with the list in terms of things that need to be considered. I've never seen these coupons before but one popped up recently that I was made aware of. And you can't tell if it's a scam or who's offering it and how much it's gonna be. You have to click through the, the pages.

And, in the end, I recommended that the person that received it just erase it because I couldn't tell if it was a scam. And so I think the documentation and everything that was said. So, my question is are you willing to continue working? And I'm sure you will. And, and I'll support it today to keep it moving because I think you're going in the right direction except for that I think these issues have to be addressed as well.

Yeah. No. Thank you for that and absolutely. They have been meeting with staff, but this is actually my first time hearing some of those recommendations and I actually think they're valid. So I would definitely continue.

That sounds great. Thank you so much for that. I appreciate your I appreciate all the testimony.

Senator Gonzalez.

I too I thank you very much also for bringing this forward. I had a question on the brand name issue that had been brought up versus, you know, perhaps a a lower cost drug. Can you just specify, like, how this would be perhaps could be reconciled in the future or how you're thinking about that? Because overall, you know, the affordability issue with drug costs is, of course, important to all of us.

So right. Yeah. And I will let the Department of Insurance tackle that question, but affordability is key.

Currently, state law actually forbids insure I mean, man drug manufacturers from offering coupons if there's a generic therapeutic equivalent that's on the formulary on a lower cost sharing tier. So this bill, if those three things are met, then the, coupon they couldn't, use a coupon for that drug. Does that answer your question?

Yes. Thank you very much. I appreciate it.

Seeing no other questions, Senator, I just wanna clarify that you are accepting the committee's amendments?

Yes. I am accepting the committee amendments.

And would you like to close?

Would like to thank the committee and staff, for all of the work that they've done on this bill. I know, you know, this has been a a conversation that we have had for many years about co pay accumulators. And so definitely look forward to continuing to work with the opposition and taking some of their, recommendations, into account and ensuring that we have that transparency that is desperately needed. And with that, respectfully ask for an aye vote.

Members, I'll be entertaining a motion. So move. Smallwood Quavas. Motions. The motion is do pass when we refer to the committee on appropriations.

Do pass as amended.

Do pass as amended and we refer to the committee on appropriations. Secretary, please call the roll.

Senators. Weber Pierson? Aye. Weber Pierson, aye. Valladares? Not voting.

Caballero? Aye. Caballero, aye. Durazo? Gonzalez? Aye. Gonzalez, aye. Grove? Aye. Padilla?

Perez? Rubio? Aye. Rubio, aye. Smallwood-Cuevas? Aye. Smallwood-Cuevas, aye. That's five zero.

That's five zero and that bill is still on a call. And I will move the consent file when appropriate Madam Chair.

Thank you. The consent file has been moved by Vice Chair. Assistant please call the roll on the consent calendar.

Did you wanna repeat what bills they are?

The bills on the consent calendar are file item one, SB 912 by Senator Cervantes with amends and file item four, SB 1271. Senator Reyes. Senators Weber Pearson?

[Roll Call]

[Roll Call]

You're welcome. Senate committee on health is concluded.