Senate Health Committee

And you may begin when you are ready. Thank you, Madam Chair. I know that it's good to be punctual, so thank you very much for your grace in letting me begin. Thank you, Chair and members. I want to start by thanking the committee staff for working with my office, and I will be accepting the committee's amendments today. With respect to the amendments related to step therapy, we just recognized it was just too difficult because we had issues on the assembly side. So we're doing that in recognition that next year we may be coming back and working with you on that. So thank you for that. Today I'm proud to present AB 1887, which will help reduce unnecessary barriers that delay or interrupt access to life-saving and life-altering treatments for Californians living with rare diseases. As chair of the California Rare Disease Caucus, this bill is the direct result of a rare disease patient roundtable that we convened in December. A rare disease is defined in federal law as a condition affecting fewer than 200,000 people in the United States. There are roughly 8,000 to 10,000 recognized rare diseases, and only about 5% have any FDA-approved treatment. Many rare diseases are genetic, progressive, and life-threatening, with early onset and rapid progression, which is why half of rare disease patients are children, and so many do not reach adulthood. For these individuals, navigating the health system is not a straight line. It is a maze. Studies show the average time to receive an accurate rare disease diagnosis is sometimes around four to six years, often involving 10 to 17 different providers, multiple diagnoses, and inappropriate treatments before anyone even considers it a rare condition. And even after that, when a patient is finally diagnosed and there is an FDA-approved treatment, too often they run into prior authorization protocols that delay or deny the only medication that has been shown to work for the disease. Research shows that when prior authorization is required, treatment can be delayed by a month or more and when it initially denied and later approved delays can reach 50 days or longer For rare disease patients especially children with rapidly progressive conditions those weeks and months are not benign They mean avoidable ER visits and hospitalizations irreversible disease progression, and some cases whether a child can walk, breathe independently, or survive to school age. AB 1887 aims to address this by accelerating prior authorization for rare disease treatments when prescribed by an appropriate specialist based on medical necessity. Specifically, this bill would require a prior authorization request for prescribed treatment to be completed within 30 days of the initial request by a provider. If the 30-day window is exceeded, this would immediately then certify the request that was submitted to the health care plan. AB 1887 is simply removing insurance-driven delays for rare disease patients to receive treatments when they're already entitled to under their existing health benefits, treatments that their plans ultimately approve in nearly every case, often after weeks or months of avoidable delay. This legislation is critical as it ensures faster access to life-saving and life-altering therapies and supports accelerated access to treatment for one patient in a million cases. Thank you, and I respectfully ask for your aye vote at the appropriate time. with me today in support of the bill are Rebecca Sponberg, pediatric rare disease clinician, Isabel Bueno, a patient living with MPS, and Alex Kahn is here on behalf of the sponsor, the California Chronic Care Coalition, to answer any technical questions.

Thank you. Madam Chair and members of the Senate Health Committee, my name is Isabel Bueso. I was born with mucoplasagotidosis type 6 or MPS6, which is a rare disorder caused by gene abnormality. This mutation means that my body lacks an insight needed to break down certain sugar products. In a person with MPS6, a buildup of weight within the cell caused bone abnormality, cardioproblem, blindness, hearing loss, pulmonary disease, and early death. There are 10,000 rare diseases, but fewer than 5% have an FDA-approved treatment. I'm one of the fortunate individuals living with a rare disease that does have a treatment option. Every week I receive infusion at UCSF Peniel General Hospital in Oakland. Although it's not a cure, this therapy helps slow the progression of my disease. Most rare disease families spend years searching for a diagnosis between 5 to 8 on average. Once a specialist finally identified an FDA-approved treatment, Patients should not have to spend additional weeks or months fighting insurance burials such as prioritization and step therapy. Every delay can mean loss of mobility, loss of organ function, progression of disease, or permanent disability. Many rare diseases are progressive and the damage occurs while waiting for approval may never be reversed. When patients lose function because treatment is delayed, the cost to the healthcare system becomes much higher than the cost of providing timely treatment. My doctors know my condition best, and their judgment should not be overruled by an insurance reviewer. Patients should not be forced to try treatment that won't work. AP 1897 removed this burial and ensures access to needed care, helping California remain a leader in rare disease innovation and a source of hope for patients like me. I respectfully urge your support for AP 1887. Thank you.

the audience that would like to register support for this bill, this is your time to come to the microphone. Please state your name, your organization, and your position only. Thank you.

Good afternoon here on behalf of the California Pharmacists Association in support. Thank you.

Good afternoon. Liz Helms, President and CEO of California Chronic Care Coalition, one of the co-sponsors of this bill, in very strong support. Thank you. Thank you.

Kevin Guzman of the California Medical Association, in support. Thank you.

Kasha Hunt with Political Solutions on behalf of the Children's Specialty Care Coalition 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. Thank you. Otiselle Campa on behalf of California Life Sciences Association also in strong support Thank you Estelle Ramirez on behalf of Lumes for Lupus and strong support for AB 1887 Thank you Good afternoon. Thank you. Good afternoon, Madam Chair and members. Julio Ramirez on behalf of the children fighting a rare disease who can't be here today. Over 70% of rare disease impact children. Please help ensure we get access to the medical treatments we need and vote aye on AB 1887. Thank you. Thank you. Tough act to follow. Good afternoon, Chair and members. Alfredo Medina here on behalf of Cedars-Sinai and strong support. Thank you. Thank you. Seeing no others who wish to register their support for this bill, we'll now open it up. If anyone would like to speak and lead opposition to this bill, This is your time to come forward to the table. Thank you. You will have a combined total of five minutes. Thank you, Chair Cassidy Heckman, on behalf of the California Association of Health Plans. I want to start by acknowledging the author's leadership in this issue area and thank the committee and the author for the amendments on step therapy. That said, we do remain opposed to AB 1887, specifically due to the section of the bill that states if the plan and provider are still in the dispute process that the claim is automatically deemed approved after 30 days. Health plans are required to respond to a prior authorization claim for prescription drugs in 72 hours or less and 24 hours or less for emergency circumstances. If there is a dispute occurring, that means that the claim is still being evaluated. What is concerning for our members is that the bill does not require providers request to be complete or to include all clinically necessary information before the clock begins. It also does not include any timelines for the provider to respond. It is unclear whether the timeline resets if the request requires additional information. Finally, we are concerned that automatically granting preferential treatment as a statutory deemed approved status to one class of exceptionally expensive drugs that can cost millions of dollars for a single dose raises market equity concerns. Again, I want to recognize the author and the sponsors for their work in this issue area and reiterate that the amendments are a step in the right direction, but we are regrettably opposed to the bill today. Good afternoon, Chair and members. Matt Akin with the Association of California Life and Health Insurance Companies, also in respectful opposition. In the interest of time, we'd just like to align my comments with my colleague at CAP and just start by, again, thanking the author, the chair, and the committee for their work on the recent amendments that do address many of our key concerns. Again, as my colleague stated, we do have some concerns as far as the automatic approval of prior authorization after 30 days. As noted, our health plans are already operating under strict timelines for PA requests. When additional clinical information is needed, however, there's currently no timeline for providers to submit that information. We just believe there should be a shared responsibility between the plans and providers to ensure the info needed to make a decision is submitted as quickly as possible so patients can get the care they need without delays. Thank you. Thank you. If there's anyone else that would like to register their opposition to this bill, this is your time to come forward to the microphone. State your name, your organization, and your position only. Seeing no one coming forward, I would like to thank the author for championing this bill and being a voice and a champion to those who really need to ensure that they have someone up here fighting for them and their very unique needs. I understand the concerns that The insurance companies have and would recommend to continue to work with them, specifically around just ensuring that all of the clinical information is there in a timely manner, and that is the reason for the potential delay. But also recognizing that this is a small number of patients that we have. I think in our analysis it says it's about 200,000 across the United States, and we have over 340 million people, and so the numbers that you have are very, very small. in this area. And so I do think that even with potential delays in getting all of the information, it should be able to be done within 30 days. But I would continue to ask you to continue to work with the opposition just to kind of tighten that up a little bit. And with that, if you'd like to close. Thank you, Madam Chair. Thank you for being a member of the Rare Disease Caucus and for your leadership in this area generally. In response to some of the issues that were raised by the opposition. I just want to point out that this bill accelerates prior authorization only for FDA-approved prescription drugs for rare diseases when there's no generic, interchangeable, biologic, or biosimilar drug, and the drug is prescribed by specialists with expertise in that disease. In practice, that means that only applies when there's only one FDA-approved treatment. So this bill was originally something that waived prior authorization instead, and we actually went to the 30-day period to give the insurers time to actually, you know, have a process. So obviously we'll continue working with them, but really this 30, we would not really want to do something that is actually resulting in more delay beyond the 30 days. And so, you know, we've already gone from something that eliminated proctorization, which was done in the state of New Mexico already, and so we do have a 30-day period in that. but we, of course, will continue working with them. So with that, I respectfully ask for your vote and want to thank my sponsors and for the testimony, Isabel, today. Thank you for being here. Thank you, and thank you to the witnesses, all those who came, and I think the youngest one we've had in this committee for a very long time. Wherever you are in the audience, you did amazing. And once we get a quorum, since we are an N of one right now, we will take a motion on that and be able to move on that bill. Thank you all so much. Thank you very much. We will now move back in the file to file item number one, AB 1979 by Assemblymember Bonta. That's a dynamic duo there. When technology and people power comes together, unstoppable. You may begin whenever you are ready. Thank you, Madam Chair and committee members. First, I'd like to start by accepting the committee's amendments and thank the chair and committee staff for working with me on this bill. AB 1979 addresses the proliferation of artificial intelligence into healthcare in three important ways First with the amendments it requires health facilities take reasonable steps to ensure that a licensed health care professional maintains the ability to exercise professional judgment when providing patient care informed by the output of a clinical decision support system. Second, it prohibits the use of a tool, system, or device using AI in health care settings to guide or instruct an unlicensed individual to do any clinical function that would require a license. And third, it clarifies provisions of the confidentiality of Medical Information Act to ensure that direct-to-consumer health care checkbots that seek to access individuals' medical records protect those records as otherwise required in law. This year, we've seen major developments in consumer-facing AI offers, access to new tools to encourage individuals to connect their medical records and ask questions purportedly to help them prepare for other doctor visits or medical information. We've also seen the rapid deployment of AI in health care and pending upheaval in our health care system from H.R. 1, where access to a human provider will be more scarce. Through just the work requirements of H.R. 1, the California Health Care Foundation estimates that 1.1 million people and medical enrollees will lose coverage in the next few years, many due simply to administrative barriers. We are also facing the loss of potentially billions of health care dollars due to changes in federal financing rules, which will financially strap and harm our providers. These losses will increase pressure on providers and health facilities as fewer people come in with insurance and there are less resources to provide care. My concern is that there will be a temptation to turn to AI to fill the needs of patients at reduced cost and loss of quality care. Automated decision systems and clinical decision support systems have been present in healthcare for decades. They are tools that use algorithms, machine learning, and medical data to assist professionals with diagnostics, treatment planning, and patient monitoring. However, it's increasingly clear that the use of AI in developing clinical decision support systems is evolving faster than laws and regulations can keep up. Protecting patient safety, keeping our professional workforce engaged in their work, and ensuring the integrity of health care will require us not to exclusively rely on AI to do things quicker and cheaper, not while we are still working to understand the potential risks along with the benefits. This bill does that by ensuring that medical records are protected by direct-to-consumer health chatbots and that licensed healthcare professionals retain their ability to exercise professional judgment when clinical decision support systems inform their care of a patient. This is the fourth policy committee hearing for this bill, and one thing we have consistently heard from opponents is agreement that technology should not be replacing human decision-making in healthcare. With the committee's amendments removing the clinical decision definition that has been called overly broad and focusing instead on protecting professional judgment in the provision of patient care, I think we have bridged that gap. Here to testify are Kathy Kennedy, who is a registered nurse and president of the California Nurses Association, the sponsor of this bill, and Deb Raji, who is a researcher focused on AI accountability. Thank you. You will have a combined total of five minutes for your presentations. Thank you. Good afternoon. Again, my name is Kathryn Kennedy. I'm a registered nurse of 46 years, president of the California Nurse Association and proud sponsor of AB 1979. As nurses our profession is both in art and science and we care for people at their most vulnerable moments What people want is a licensed clinician who uses their professional judgment clinical skills lived experiences and the human compassion to provide safe and effective care. Bedside nurses do not just execute tasks. We are constantly assessing, evaluating, planning care through the nursing process to provide the individual holistic and quality care for each of our patients every single day. Our professional judgment cannot be reduced to an algorithmic output. The issue is not whether nurses use technology. We do. It's how that technology is deployed, and if an AI system is designed or used in a manner that its output controls the clinical decision and the nurse's clinical judgment becomes secondary, then that is when patient safety is potentially at risk. When I hand off my patient at the end of the shift, I'm not just passing along a summary of my patient's chart. I'm using my clinical judgment to determine what interventions are essential for the next nurse to know about my patient. AI may be able to generate a summary or to organize the information. However, it cannot assess our patients or catch the subtle changes that nurses see, touch, or smell. Nor should AI be allowed to determine the substance of our assessments, handoffs, or any clinical decision without the ability of the nurse's clinical judgment to be in control of all of the communication. AB 1979 draws a clear and practical line. Licensed health care professionals must retain the ability to exercise their independent clinical and professional judgment, and this bill makes clear that patient data remains protected by existing health privacy law when it passes through an AI-enabled platform. For the nurses, this bill is about patient safety, professional integrity, and preserving trust in the human beings who provide patient care. So I thank you, and I respectfully ask for your aye vote. Hi, I'm Deb Raju. I'm a computer scientist at UC Berkeley that works on AI accountability in public interest deployment settings. I am an advisor for the Health AI Partnership, which is a coalition of different health systems adopting AI technology, as well as publish various articles on AI accountability that's been cited by the Federal Trade Commission, the National Institute of Standards Technology, ONC, and other regulators. Under the Hippocratic Oath, physicians and other health workers are charged with a heavy mandate. First, do no harm. However, so far the evidence is already clear that many AI systems can fail, sometimes catastrophically, often perniciously, in unexpected ways that risk causing real and lasting harm, especially to marginalized populations if deployed prematurely and inappropriately. Research has already revealed that much of the benchmark performance being reported by corporate vendors of AI health technology is inadequately tested. The contrived scenarios and medical exam style test vendors report do not capture actual performance outcomes within a complex deployment setting. In domains like mental health care, we already know that features for which these tools have been optimized in mainstream consumer products do not align with the expectations of practical and ethical guidelines for licensed professionals. In addition to this, regulatory arbitrage, internal tool development, and a still immature emergent regulatory ecosystem means that currently deployed tools do not always go through a rigorous approval process. As a result the health systems deploying this technology tend to overestimate what this technology is capable of especially in the absence of human oversight As outlined in AB 1979 health systems deploying AI technology need to take seriously their responsibility to adopt integrate and monitor AI systems that they introduce into clinical settings with care. Through participation from AI users and the impacted population in the healthcare setting, we protect the most vulnerable patients amongst us from further harm. Thank you. Thank you. If there's anyone else in the audience that would like to register your support for this bill, please come forward to the microphone, state your name, your organization, and your position only. Thank you. Arlise Farba, registered nurse with California Nurse Association. I support. Good afternoon. I'm Roxanne Montgomery with the California Nurse Association ICU registered nurse at Sutter, and I support. Hello, Madam Chair and members of the committee. Yvonne Fernandez on behalf of the California Federation of Labor Unions, in support. Good afternoon, J.P. Hanna on behalf of the California Nurses Association, proud sponsor of this measure. Thank you. Julie Nielsen on behalf of the National Union of Healthcare Workers, in support. Bindu Mukamala on behalf of the National Association of Social Workers, California Chapter, in strong support. Alejandro Solis on behalf of CPCA Advocates and support. Thank you. Seeing no one else who would like to register their support. If there's anyone who would like to speak as lead opposition, this is your time to come forward now to the table. You have five minutes for your presentation. Good afternoon, Chair and members. Mark Farouk on behalf of the California Hospital Association. I wanted to begin by thanking the author, her staff, the committee chair, as well as the committee staff for their work on the amendments to this bill. I will be brief. I just had two specific comments. There was an issue raised earlier about the potential incentive due to the extreme cuts to the health care system resulting from H.R. 1. I just wanted to respond to that and reiterate and ensure, based on the multiple letters that we've sent and the multiple committees that we've been in to testify, that we continue to believe that medical professionals should remain in the loop and have the final decision, that this technology is being used to assist and not replace, that it is being used to ensure appropriate and positive patient outcomes and reduce the workload for medical professionals. Lastly, we'd just like to say that with the amendments, CHA will be moving to a neutral position. We do have a remaining concern related to the definition of clinical decision support system, but we look forward to continuing to work with the author as well as the health and privacy committees to further refine that definition. Thank you. Thank you. If there's anyone else that would like to speak in opposition or tween, this is your time. Come to the microphone. State your name, your organization, and your position only. Thank you. Thank you, Madam Chair and members. MJDS on behalf of Kaiser Permanente. We would align our comments with our colleague from CHA and thank the committee staff and the author for working through the various amendments. We are still reviewing them, but we are pleased to move our opposition to a neutral position. Thank you. Thank you. Madam Chair, members, John Winger on behalf of ADVAMED, the Advanced Medical Technology Association. We currently have an opposed and less amended position, but reviewing the amendments, and thank the author for the ongoing dialogue. Thank you, Madam Chair and members of the committee. David Gonzalez, a matter of APG, America's Vision Groups. Thank you for the author for your work and looking forward to removing your opposition. Thank you. Good afternoon. George Sorries with the California Medical Association, moving from an opposed unless I'm in a position to neutral and align my comments with my colleague from CHA. Thank you to everyone who's put the work in on this bill. Ryan Spencer with the California Radiological Society, also removing their opposition, moving to neutral for the reasons previously stated. Thank you. Jonathan Clay on behalf of Scripps Health, removing our opposition. Alexis Rodriguez with the California Chamber of Commerce, also expecting to move to a neutral position with the amendments. Thank you so much. Appreciate it. Good afternoon, Gilbert Lahr here with Biocom with an opposed unless amended position, but we thank the author and we'll review the amendments once they're published. Thanks. Good afternoon, Olga Shiloh on behalf of the California Association of Helplands. We will also remove our opposition. Thank you. Lawrence Gaden with the California Dental Association, currently with an opposed unless amended position, but we're still reviewing the amendments, and thank you for your work. Jasmine Valle on behalf of the Civil Justice Association of California. We have an opposed unless amended position, but also look forward to reevaluating our position once we look at the amendments. Thank you. Ms. Short on behalf of Adventist Health, removing our opposition. Is there anyone else in opposition? In opposition, a tweener, or in support at this point? Very good. The bill comes to the committee, and it's me. And I'm not sure if the chair may have advised you that this week is the end of the time for committees to hear bills, and so everybody's running to a number of committees. And so it's not a reflection either of the author or of the work of this committee. Everybody takes it really seriously. So I don't have any questions. You've done an excellent job in working towards a position where it looks like there may be no opposition, which is really important in this arena. And so I'll allow you to conclude. Thank you, Senator. I want to just state and share that I think the removal of opposition is really a testament to the work that we've been able to do with this committee and certainly our staff with many of the advocates and our proponents of this measure with the common good in mind, which is to ensure that we continue to have high-quality health care system that involves and engages humans in making those critical decisions and that also takes into account, as was stated by our testimony, that this is still a very evolving field with AI, making a lot of life and death decisions potentially should we not impose the necessary guardrails to make sure that we're doing that. We can't be caught sleepwalking in this world right now where AI tools are so evolved within the space of licensed and replacing licensed healthcare professionals, which I think we share a common agenda to not do so. Providing health care requires compassion, empathy, and real-world judgment that cannot be captured in patterns and algorithms. Technology should assist human clinicians not replace them With that I respectfully request your aye vote Very good This bill when we get a quorum we take a motion on it And I believe there's a recommendation from the chair. So we'll wait until we get more people back. You have the next bill. I do. Which is AB 2161. Thank you so much for your testimony. Thank you, chair and members. I'm proud to present AB 2161 to minimize the harm of new federal rules that impose harmful and ineffective work requirements on Medi-Cal recipients. AB 2161 is one of several bills this committee will be hearing and considering today on implementation of H.R. 1. And the approach they all take is to comply with the law while preserving coverage for Californians to the maximum extent possible. AB 2161 will ensure California does everything in our power to help people maintain their Medi-Cal coverage. As you know, H.R. 1 proposes new work requirements tied to health care coverage. But let's be clear, work requirements are not about work. They are about paperwork. They are about throwing up hurdles that result in people losing coverage even when they are working, eligible, and trying to comply. AB 2161 implements the federal law in a way that preserves Medi-Cal coverage to the maximum extent possible. California should not go beyond federal requirements to impose additional barriers to care. Specifically, the bill will promote the use of existing data and administrative tools to maintain coverage and reduce churn, which is expensive and bad for people. It prevents the extension of federal work requirements to state-funded Medi-Cal populations where the state has discretion so we don't double down on failed policy. It also adds protections for Medi-Cal members to make sure they can get and keep coverage. It requires the Department of Health Care Services to measure compliance using specific data sources. It requires timely and informative notices. It requires due process, making sure people are informed of their rights to appeal a decision to terminate their coverage. and it has a contingency provision requiring DHCS to implement the new eligibility rules only to the extent that federal law requires implementing these eligibility rules that are in place. Should that change at the federal level, this bill will allow the state to lift these burdensome requirements in the state. Before I close, I want to recognize, as pointed out in committee analysis, there is some overlap between this bill and provisions that were adopted just earlier this week in SB 164. the budget trailer bill to implement HR1. In addition, in June, the Federal Center for Medicare and Medicaid Services, or CMS, released implementing regulations that make these harmful policies even worse, putting the health care coverage of medically frail individuals at risk and prompting the state of California and 25 other states to sue to block implementation of this rule. So there's a lot going on here, and I and my team are actively reviewing the implications of all of these very recent actions. on this bill. Should this bill move forward today, I am committed to work on a set of amendments to reconcile a language while the bill is an Appropriations Committee. I appreciate the work of this committee on the bill and we plan to stay in close touch with the committee and the chair and staff as we work through these next steps on this bill. Here to testify is Linda Way with the Western Center on Law and Poverty, a co-sponsor of the bill, and Michelle Johnston with with the National Multiple Sclerosis Society. Thank you very much. You're welcome. Thank you. Good afternoon. Linda Way with Western Center on Law and Poverty, proud co of AB 2161 which fights back against cruel federal cuts that will result in over 2 million Californians losing Medi through the imposition of work reporting requirements and more frequent renewals The Congressional Budget Office finds that work reporting requirements not only fails to increase employment rates or average earnings, but also delays access to care and decreases program participation by creating an additional administrative barrier. In fact, Arkansas and Georgia's experience with Medicaid work reporting requirements led to a decrease in health coverage with no change in employment outcomes. Work reporting requirements is unnecessary as most Medi-Cal members who can work are already working. Data shows that 63% of non-disabled, non-elderly adults enrolled in Medi-Cal are already working. 14% are not working due to being a caretaker for a family member and 8% are students. AB 2161 limits the administration's endorsement of H.R. 1's work reporting requirements through imposition of state-funded immigrants who are more likely to have legal and logistical issues proving work reporting compliance, even if they are working. This bill helps people keep their Medi-Cal coverage by cutting the red tape, using existing data, and improved notices. Medi-Cal coverage not only decreases mortality and improves health outcomes, but is also linked to reductions in poverty rates, food insecurity, and evictions. Therefore, urge your aye vote. Thank you. Thank you very much. Good afternoon. My name is Michelle Johnston, Director of Policy and Advocacy for the National Multiple Sclerosis Society, and I also live with MS. Thank you for giving me the opportunity to speak today in support of AB 2161. Multiple sclerosis is an unpredictable disease of the central nervous system that is typically diagnosed between the ages of 20 and 50. Symptoms vary from person to person and may include disabling fatigue, mobility challenges, cognitive changes, and vision issues. Nearly one quarter of the 68,000 Californians living with MS are covered by Medi-Cal, not including those who are receiving Medi-Cal home and community-based services. Work requirements are a barrier to access for people living with MS and other chronic illnesses. Many people with MS who may not meet the definition of disabled have symptoms that make it difficult to maintain full-time or even part-time employment, both in the short and the long term. About 80% of people living with MS experience fatigue, and over half of people with MS experience some form of cognitive symptoms. These common symptoms will make it significantly more likely that eligible individuals will lose their Medi-Cal access as they struggle to navigate complex administrative procedures to prove that they're either working or qualify for an exemption. Individuals on Medi-Cal have spoken to me about the stress and anxiety of trying to manage the paperwork while living with the disease that makes being organized a challenge. Losing coverage can lead to delays or gaps in care, may result in serious, long-term, and irreversible consequences and disease progression. MS profoundly affects not only those diagnosed with the disease, but also their care partners, some of whom are also enrolled in Medi-Cal. Many frequently have to take time off work to care for their loved ones, which can result in employment disruptions that may threaten their own health coverage. We appreciate the strategies in AB 2161 to minimize the administrative burdens, to apply work requirements in the least harmful way, and to give people multiple options for submitting their data, including phone and electronic options. We urge your support of this important legislation Thank you Thank you very much and thank you for sharing your personal story I appreciate the difficulty Thank you This is the time for those in support Ryan Spencer on behalf of the American College of OBGYNs, District 9, and the California Podiatric Medical Association, both in support. Thank you. Kelly LaRue for the California Kidney Care Alliance in support. Thank you. Thank you. with Children Now in support. Tony Anderson, the Association of Regional Center Agencies in support. Nasset Short on behalf of Peach representing Community Safety Net Hospitals in support. Good afternoon, Angela Pontus on behalf of Planned Parenthood Affiliates of California in support. Good afternoon, Darby Kernan on behalf of LeadingAge California in support. Kathy Mossberg on behalf of APLA Health and San Francisco AIDS Foundation in support. Lawrence Gayden on behalf of the California Dental Association in support. Thank you. Anai Matias Santiago with Latina Advocates here on behalf of Hispanas Organizer Political Equality in support. Thank you. Thank you. Good afternoon. Aston Georgiola-Williams with California LGBTQ Health and Human Services Network in support. Thank you. Thank you. Sarah Weber with the Drug Policy Alliance in support. Monica Madreda with the Coalition for Human Immigrant Rights in support. Good afternoon. Eric Paredes with the California Faculty Association in support. Andy Liebenbaum County of Los Angeles in support. Good afternoon, Tweedo with the Southeast Asia Resource Action Center in support. Thanks. Thank you. Dindu Mu Kamala on behalf of the National Association of Social Workers, California Chapter, in support. Johan Cardenas with the California Panac-Nic Health Network in strong support. Kelly Lou Densmore with the East Bay Community Law Center in support. Good afternoon. Chow Nguyen with the East Bay Community Law Center in support.

Jeff Neal on behalf of the Board of Supervisors of San Diego County, also in support. Mary Creasy with the Children's Partnership in support. Lynn Kins representing the Bleeding Disorders Council of California and the California Rare Disease Access Coalition in support. Thank you. Cher Gonzalez on behalf of my client, the American Diabetes Association, in strong support. Alejandro Solis on behalf of CPCA Advocates, in support. Thank you. Nicole Lachlan with the East Bay Community Law Center in support. Isis Wilson with the East Bay Community Law Center in support. Van Jones with East Bay Community Law Center, also a medical recipient, strong support, thank you. Thank you. Anna Alvarez on behalf of Health Access California, Healthy Contra Costa, and the Health Rock Coalition in support. Christine Smith on behalf of Justice and Aging and Disability Rights California in support. Thank you. Cleo Bluthenthal on behalf of the California Community Foundation in strong support.

Divya Shiv with the California Alliance of Child and Family Services in support. Rand Martin on behalf of the AIDS Healthcare Foundation in support. Thank you. Very much. Seeing no other people in support or organization in support, we'll move on to opposition. We do not have official opposition listed. Is there anyone here that would like to testify in opposition? How about just to add on as a Me Too in opposition? Okay, very good. Well, congratulations again. I think this is really important. I mean, the bottom line is this is specifically designed to make sure that people fall off the rolls. It doesn't make a lot of sense, but we're going to have to deal with it, and the more that we can make it possible for people to actually be able to comply, even if it's comply according to the state, that's going to be really important. So I'll allow you to conclude.

We will take it up when we get more members. Thank you. Thank you very much for being here. Assemblymember Shavo. Can we begin with AB 539? Perfect. Great. Welcome. Thank you so much. Thank you, Madam Chair and the whole committee. That's how it goes on these days. Yes. Thank you so much for the opportunity to present AB 539, the Timely Care Act. First, I would like to thank the committee staff for their work on this measure, and I will be accepting the committee amendments. This bill is really about putting patients where they belong, at the center of care. No one battling chronic illness should have to fight their insurance companies just to keep getting treatment that has already been prescribed and approved. But right now, that's the reality of prior authorization for too many people. Doctors across the state are sounding the alarm. The current system of prior authorization is not just inefficient it harmful It so burdensome that some patients give up on treatment altogether Doctors are having to use unbelievable amounts of resources and taking them away from care And that's not just a bureaucratic issue. It's a health issue. Take, for example, what we're hearing from radiation oncologists. They're seeing critical medications, ones that help ease the pain and side effects of cancer treatment, being delayed by frequent reauthorizations. And as someone who has a mom who just started radiation treatment yesterday, that is particularly poignant for me right now. Imagine going through the grueling process of cancer treatment, finally getting the prescription to help with the pain, only to be told that your insurance no longer thinks it's medically necessary. I've also heard of people who are trying to get physical therapy or mental health appointments, and they're being pushed towards two-week authorization. So they can't even get appointments in time to then have to go through getting another authorization from their insurance company. We have to do better, and we can. This bill will eliminate unnecessary red tape and help ensure patients get the care they need when they need it by extending the duration of approved prior authorizations to one year or the duration of the physician's prescribed treatment. We should be very clear that what prior authorizations is and is not. Prior authorization is a cost containment measure. It is not a patient safety mechanism. AB 539 will ease the burden on physicians and help patients stay on track with treatments they need. It's a common sense change that will have a real human impact. Here to testify in support is Dr. Anna Yap on behalf of our sponsor, California Medical Association, and Liz Helms on behalf of the Chronic Care Coalition. Welcome. You may begin. Thank you so much. Good afternoon. I'm Dr. Anna Yap, an emergency physician practicing here in Sacramento, speaking on behalf of the California Medical Association as a proud sponsor of AB539. As an emergency physician, I often meet patients after our health care system has already failed them. Many of those failures begin long before they arrive in my emergency department with delays caused by prior authorization. I've cared for countless patients who spend weeks trying to get a test or treatment their physician already prescribed, and by the time they reach the emergency department, they're frustrated, their symptoms have often worsened, and what could have been managed earlier has become a much more costly episode of care. The irony is that health plans often agree with the physician. The test or treatment ultimately gets approved. The problem isn't always that the answer is no, it's that the answer comes too late. That's why AB 539 is so important. We're talking about treatments the health plan has already approved and already determined are medically appropriate. Yet physicians are forced to repeatedly seek authorization for the same exact treatment when nothing has changed. That doesn't improve patient safety. it does improve costs. It creates unnecessary administrative burdens while delaying care and drives up health care costs. According to the American Medical Association, 95% of physicians report that prior authorization delays necessary care, more than one in four report that it has led to a serious adverse event, and one in five report that has resulted in a patient's hospitalization. Prior authorization also contributes to California's physician workforce challenges. Physicians spend an average of 13 hours each week completing prior authorizations instead of caring for patients and 94% report it contributes to physician burnout At a time when Californians are already struggling to access care we should be making it easier for doctors to care for patients not paperwork AB539 is a common sense reform that should help patients get the appropriate care they need It should not require physicians to repeatedly prove that yesterday's approved treatment is still appropriate today. By extending approved prior authorizations for the course of treatment up to one year, this bill protects continuity care, reduces unnecessary bureaucracy, and helps patients receive the timely care that they need to deserve. On behalf of the CMA, I respectfully ask for your aye vote. Thank you. Thank you very much.

in their life Thank you very much for your testimony today Anyone who would like to sign on as a Me Too please come forward State your name for the record and the organization you represent Christine Smith, Health Access California, in support. Thank you. Vanessa Kahina for the California Academy of Family Physicians, here in support. Ryan Spencer on behalf of the California Radiological Society, the California Podiatric Medical Association, and the Crohn's and Colitis Foundation, all in support. Good afternoon. Linda Way with Western Center on Law and Poverty, in support. Angela Pontes on behalf of Planned Parenthood Affiliates of California, in support. Good afternoon. Kelly MacMillan, in support on behalf of American Academy of Pediatrics, California, the Children's Specialty Care Coalition, a California dermatologist, and the California Association of Marriage and Family Therapists. Thank you. Johan Cardenas with the California Panacnic Health Network in support. Josh Cochran on behalf of the Santa Clara County Board of Supervisors and also on behalf of the California Association of Public Hospitals and Health Systems, both in support.

Thank you.

Chair Gonzalez, on behalf of my clients, the American Diabetes Association, the Association of Northern California Oncologists, and the Medical Oncology Association of Southern California, all in strong support. Lynn Kinst, representing the Bleeding Disorders Council of California and the California Rare Disease Access Coalition, in strong support. Jennifer Snyder, on behalf of the Physician Association of California, in support. Okay. Is anyone else in support? Seeing none, how about witnesses in opposition? Welcome. Thank you chair and members. Nick on behalf of the California Association of Health Plans. In respectful opposition to AB 539, unless amended, AB 539, as you heard, would require authorization approvals to remain valid for at least one year, regardless of changes in a patient's condition or treatment plan. Prior authorization is a targeted tool used to ensure care is medically necessary, evidence-based, and appropriate for the patient. A blanket one-year approval could undermine important clinical reassessments and patient safety safeguards. We do want to acknowledge the amendments that are going into the bill today, some of which are inspired at least by suggestions that we had made in our opposition letter, but unfortunately the amendments do not go far enough. Patient needs can change significantly over the course of the year. Without periodic checks and balances, this bill could increase unnecessary utilization, duplicative care, and thus lead to program and market integrity problems. On the issue of program integrity, I would just point out that the state of California, in response to concerns about waste in the Medi-Cal program has actually increased utilization management over the past couple of years, including prior authorization on certain services. As one example, in 2022, California temporarily suspended authorization for care for most prescriptions as part of the transition to the Medi-Cal RX program. That single policy change led to nearly $180 million in fraudulent payments. And then so that caused the state to reverse course. In the 25-26 state budget, it reinstated utilization management, step therapy, and prior authorization in Medi-Cal for prescription drugs. These program integrity issues are also present in the commercial markets, and we fear that this bill could raise costs unnecessarily. We're not oblivious to the fact that the system could use reforms. In fact, the health plans nationally have embarked on a voluntary effort to make the process better for providers and patients. One of the main reforms that they had voluntarily agreed to was to reduce the number of prior authorizations, and that has led to an 11 percent reduction in prior authorization across medical services, representing about 6.5 million less prior authorizations on a national basis, and that work continues. We believe the bill could be further amended, require authorization requests to be submitted electronically. You know, the process would definitely improve if that were to happen. Ensure requests are clinically complete before the timeline reviews begin, and limit authorization validity to no more than six months in statute. So I'll stop there, but we respectfully oppose the bill at this time. Thank you very much. Madam Chair and members, Stephanie Watkins on behalf of the Association of California Life and Health Insurance Companies here today respectfully with the opposed unless amended position as well. In the interest of time, I won't repeat the concerns that were mentioned earlier by my colleague, but I would like to highlight the work that we are currently doing. Last year, the legislature did pass SB 306, which was a comprehensive and holistic look at the prior authorization process in California that would allow CDI and DMHC to set forward a platform and a process for all plans to submit all prior authorizations for review and to make a global determination of whether or not they are appropriate to continue. We think that that work that is happening now, most recently there were several work groups, as well as the departments recently released the stakeholder platform and the forms that will be filled out by the plans. We expect in December for all of that data to be submitted to the department, and July of next year we expect a comprehensive list to be released by the departments of those procedures or prescription drugs determined to not be appropriate for prior authorization. We appreciate the time and all of the conversations that we had around prior authorization that's not lost on us. We are committed to that process with both our regulators and feel that is the more appropriate and the more holistic approach. So for those reasons and the ones illustrated by my colleague, we are unfortunately opposed unless amended to the bill today, but do look forward to conversations that the bill moves forward today. Thank you. Thank you very much. Now is the time for those in opposition to come forward and state your opposition. Alexis Rodriguez of the California Chamber of Commerce with an opposed unless amended position. Thank you. Thank you. Madam Chair and members, Rand Martin on behalf of the AIDS Healthcare Foundation, which sits at a unique intersection of provider and plan. Opposed unless amended, but happy to provide any insight that we can to the author. Thank you. Thank you very much. Anyone else in opposition? Seeing no one else, we'll bring you back to the committee for questions or concerns. Perfect timing. Any questions or concerns? Yes. Thank you. Thank you Madam Chair Thank you I know we had conversations about this bill I think the plans have a right to protect you know cost protections and things like that and address fraud issues if they exist and make sure that there a mechanism to do that But I do have to share with you publicly just what I shared with you privately is that we have tremendous calls that come in for constituent services about trying to get into a doctor and waiting for a preauthorization, or excuse me, an authorization that takes two, three, four weeks. to get approved. One of them was actually my district director who was trying to get in to get her back checked, and it took three weeks. And so for three weeks, she's flat on her back. And so I get it. I get that we need to extend the pre-authorization. You would hope that physicians were good stewards of that responsibility and that we didn't have fraud. I hate that this building makes policy based on one bad actor. And I know this pits our plans that are trying to control costs because those costs are going up and our medical providers against each other, which is unfortunate. Again, in this case, I know that we've had conversations about it. I do. I'm very sympathetic to what you're trying to solve. There is a strong opposed recommendation on our side, and I apologize for that. But if you need my vote, I'll give it to you. I'd always love your vote. Totally. But, yeah, no, I appreciate your comments. And I think at the end of the day, and, you know, as you mentioned, we had this conversation, but, you know, this is the prior authorization process is not meant to be fraud prevention. It is cost control. That is what it is. And it controls cost largely because it deters, it denies or it deters care. And so, you know, if something's already, this bill is really about something already approved. So the electronic transmittal doesn't even apply to this because it's already been approved. But this is about something that's already approved and just making sure that whatever that course of treatment is, so if the course of treatment is something that it needs to be checked in on earlier to the opposition's point, of the course of treatment can change? Absolutely. And so physicians have an opportunity to say, you know, I'm going to let you try. I've had that experience, right? I'm going to let you try this out for three months, and then we're going to check back in and see how it's going, and we'll give you another prescription for this or we'll give you another treatment for this and give you more time if it's working, right? And so that still all can happen under this bill. This is just saying if it's already agreed to, The physician says it needs to happen. The insurer says, yes, this should be approved, that it is approved for the course of treatment up to a year. It can be less than a year, but up to a year. If everybody is in agreement, why are we having to go back to the table over and over and over and over again during the year? Okay. Any other questions, comments, concerns? Seeing none, we'll allow you to conclude. Thank you so much. I think that was making a case for it. I know you have a lot of bills today, so with that, respectfully request an aye vote. Very good. I will entertain a motion on this. No? Oh, we don't have a quorum. Never mind. Okay. Sorry, I was trying to get business done. It's okay. Whenever you can. Trying to be efficient. So when we get a quorum, we'll take up your bill. And I have one more. Appreciate it. And you have one more AB You do I do AB 2311 Yes Thank you Madam Chair again and members So I want to thank you for the opportunity to present AB 2311, the Public Hospital Physician Stability Act. And I want to first start by thanking the Chair whenever she gets back and the committee for their work on this bill. I will be accepting the committee amendments today which limit eligibility to district hospitals that either have a public payer mix greater than 75% or have received a loan under the distressed hospital loan program. So as we know, California's public health care districts are a critical lifeline serving some of the most underserved and most diverse communities in our state. Taxpayers invest in these local hospitals, which are locally governed, publicly accountable, and often serve a higher share of Medi-Cal patients than the state average. However, they're facing growing financial pressure, especially with recent federal actions under H.R. 1, which significantly cut Medi-Cal funding. And at the same time, these hospitals, which are often in rural communities or low-income communities, are uniquely disadvantaged. They are the only public hospitals in California that cannot directly employ physicians. This restriction makes it harder for district hospitals to recruit and retain doctors, especially as physicians now are increasingly wanting stable employment with predictable salaries and benefits. They don't want to be sole proprietors. They don't want to have to run a business on the side. They just want to go in, take care of patients, and go home. Without the ability to directly hire physicians, many of these hospitals face worsening staffing shortages and uncertainty in maintaining services. AB 2311 simply allows public health care district hospitals to directly employ physicians, just like the other public hospitals, FQHCs, and academic medical centers already can. This added flexibility will help hospitals compete in the healthcare labor market, stabilize their workforce, and ensure patients continue to receive timely care. I appreciate California Medical Association's willingness to work with my office and reach a final agreement to address their concerns. We share the goal of both effectively protecting doctors' clinical judgment, as well as providing flexibility that allows hospitals to keep providing high-quality care in their communities. While all public hospitals should have the same tool at their disposal, this policy has been thoughtfully modified to the most vulnerable and underserved to ensure that the best results for our community. The committee amendments speak to the gradual change while ensuring the most vulnerable hospitals can recruit and retain physicians to serve those who struggle the most to pay for health care. We know that hospitals with a high government payer mix struggle to maintain adequate physician contracts. The hospital that serves my district, Antelope Valley, has a 90% government payer mix. I am hopeful that this compromise allows us to assist those hospitals that are the most impacted by HR1, who without this will struggle to provide care to the Medi-Cal and Medicare beneficiaries they serve. Of the 16 hospitals, the bill originally intended to capture the amendments preserve 13 of these hospitals, those hospitals that are struggling the most and need it the most. Here to testify in support is Sarah Bridge with the Association of California Healthcare Districts the sponsor of the bill and Felipe Fuentes from Palomare Health Hospital Thank you. You will have a combined total of five minutes for your presentations. Thank you. And thank you, Madam Chair and members of the committee. Sarah Bridge, on behalf of the Association of California Healthcare Districts, here is proud sponsors of the AB 2311. I want to start by thanking the author for her continued leadership in this space, the committee staff, and the stakeholders for their diligent work on the bill. We believe AB 2311 represents a very significant and meaningful step towards achieving equity for public hospitals by addressing the most vulnerable public hospitals first. As you can see, the bill in front of you has undergone significant amendments to address opposition's concerns. We appreciate the willingness of the California Medical Association and others to come to the table and meaningfully address the looming threats of HR1. While we strive for equity across all public hospitals, we understand that CMA's historical concerns and appreciate the honest step toward assisting those with the most significant pending cuts. With the most significant pending cuts in healthcare in decades due to HR1 impacts, district hospitals will continue to struggle to recruit and retain physicians. where their other public counterparts and federally qualified health centers, over 1,000 clinical sites, will maintain this additional tool at their disposal to recruit and retain. This committee, alongside the Assembly and the budget subcommittees, have meaningfully endeavored into analyzing these looming impacts. In those hearings, you heard directly from district hospitals who shared the intense and real struggle they faced given these cuts, including concerns about the willingness of physicians to contract with hospitals of less desirable pair mixes. While AB 2311 may no longer account for all district hospitals, we understand progress is often incremental. AB 2311 is a critical and meaningful step to ensuring that all Californians continue to receive primary and specialty care in their communities, regardless of where they choose to seek care. For these reasons, we respectfully ask for your aye vote. Thank you. Good afternoon, Madam Chair and members of the committee. Felipe Fuentes here on behalf of Palomar Health, the largest public health care district in California, in strong support of Assembly Bill 2311. Palomar Health exists for one reason, and that's to care for everyone who comes through their doors, regardless of their ability to pay. Every day, approximately 80% of our patients are covered by Medicare or Medi-Cal or receive uncompensated care, yet we continue to provide life-saving services across more than 2,200 square miles, serving over 1 million Californians. Today, district hospitals are the only public hospitals in California that generally cannot employ physicians. County hospitals can, UC hospitals can, critical access hospitals can, and federally qualified health centers can. But public health care districts like Palomar often cannot, And that places us at a significant competitive disadvantage when trying to recruit physicians into communities that need the care the most. This bill simply provides another recruitment tool. It does not eliminate physician independence. In fact, the bill expressly prohibits hospitals from interfering with a physician's professional judgment, requires approval by the medical staff, preserves contracting as an option, and includes a sunset and reporting requirement so that the legislature can fully evaluate its effectiveness. The committee amendments also appropriately narrow the bill to hospitals serving the greatest public need. Those with exceptionally high Medicare and Medi-Cal populations are those that have received distressed hospital loan program assistance. Palomar Health meets that standard. At a time when California faces physician shortages, financials, pressure on safety net providers and growing demand for care, we should not deny public district hospitals a workforce tool that other public systems already have. AB 2311 is about provider equity, stronger recruitment, and ensuring patients continue to have timely access to care in their own communities. And for those reasons, we strongly urge the committee's support of Assembly Bill 2311. Thank you. If there's anyone else in the audience that would like to register their support for this Bill, please come to the microphone, state your name, your organization, and your position only. Thank you. Karen Freese, Del Puerto Health Care District, in support. Thank you. Good afternoon, Madam Chair and members. Connie Delgado on behalf of the District Hospital Leadership Forum, in support. Thank you. Good afternoon, Madam Chair and members.

Thank you. Mary Casillas from San Benito Health Care District in support. Thank you. Seeing no others that would like to speak in support, If there's anyone who would like to speak as lead opposition, this is your time to come to the table. And you will have a combined total of five minutes. Thank you. Good afternoon, Chair and members of the committee. My name is John Cowan, Executive Director of Government Relations for El Camino Health. We oppose AB 2311. El Camino Health originally supported this bill, but committee amendments now carve out three Bay Area district hospitals while leaving 59 other public hospitals untouched. That's why we oppose this today. Here is the contradiction at the heart of these amendments. The California Medical Association, or CMA, has long opposed physician employment by district hospitals, arguing it violates the corporate practice of medicine doctrine and erodes physician independence. But CMA's new amendment says that concern applies to only three public hospitals, not the other 59. One of CMA's largest members has already built a network of 12,000 employed physicians and wants to weaken those three independent hospitals specifically. If corporate practice of medicine were truly the concern, it would apply everywhere equally. This bill does not, thus making it clearly biased. A hospital's payer mix, its ratio of Medicare, Medi-Cal, and privately insured patients has absolutely nothing to do with whether it can be trusted to employ its own physicians. CMA knows this. This amendment is a tactic. It hands more leverage over three independent public hospitals to a large health system that has already faced multiple settlements for driving up health care costs through aggressive consolidation. This is not about protecting patients or physicians. It's about market dominance. Independent public hospitals like El Camino Health make decisions based on what's right for the patient in front of us, not a health system's bottom line. That's what locally governed human-scale care looks like, and it's exactly what's at risk when hospitals are pressured into affiliated with large health systems. This committee should reject carve-out language built on a contradiction and designed to serve consolidation, not patients. I respectfully ask you to vote no on AB 2311 as amended. Good afternoon Madam Chair members of the committee My name is Angela Hill I a legislative advocate with the California Medical Association I do want to begin by thanking the committee staff the chair and the author for accepting the committee amendments CMA has been in discussions with the author's office and the sponsors since March on our desire to narrow the eligibility of this exemption. and we're really grateful to have reached a resolution that is reflected in the committee's analysis. And with these narrowing amendments, we will be removing our opposition. Again, I do want to thank the author, the committee, the staff for their collaboration and happy to answer any questions. Thank you. If there's anyone else in the audience who would like to register opposition or tween a position, this is your time to come to the microphone, state your name, your organization, and your position only. Yes, Ryan Spencer. I'm actually a tweener. Thank you for the committee and the author of Recepting Amendments, the California Radiological Society, the California Society of Pathologists, and the... It's a long day, man. I know. It's a long day. The California Orthopedic Association are removing their opposition. Thank you. Yeah, exactly. Thank you. Harassment here.

Angus Cochran with Washington Township Healthcare District and Washington Health in Fremont, in opposition. Thank you. Seeing that there's no one else that would like to register their tweener or opposition position, we'll bring it back to the committee. Senator Caballero? So I heard the opposition. I represent a rural agricultural district and was one of the co-authors in the distressed hospital loan program because we had a hospital in our community that closed. And so I appreciate the amendments, and I appreciate the opportunity to start with a specifically defined type of hospital that gives us an opportunity to really work and see if it works. I think we're going to need the flexibility as we move into a different health care model for there to be different types for different hospitals. And I'm always glad to see the people here from San Benito County because that was the second hospital in my district that filed for bankruptcy. And so both of those hospitals were the only hospitals in the county, and they still remain the only hospitals. We were able to get Madera Hospital back open again, but it wasn't without some incredible resources put towards it and kind of a reorganization. So I appreciate what you're doing, and I'm going to support your bill today. I'm curiously optimistic on this working, so I appreciate it. Thank you, Madam Chair. Thank you. Vice Chair Valladere. Yeah, I just want to echo the sentiments of Senator Caballero. I think this is a really smart, good bill. As was mentioned earlier, this is important to hospital districts like the Antelope Valley Hospital District. and I mean even if Senator Grover here should be talking about Ridgecrest Hospital which has been going through some really tough times and as a result of those tough times we seen people from Ridgecrest come to the Antelope Valley for services and that like a three commute So I love this bill Would love to be a co if you would have me And just thank you for bringing it forward. Thank you. I'd love to have you as a co-author. Well, I want to thank the authors so much and also the sponsors and CMA for working so closely with the committee staff to get this right, to kind of thread that fine needle. This is not a CMA bill. It's not a CMA-sponsored bill. And, however, understanding that there are different hospitals that need different things, and certain hospitals have more money and more resources than others and can use those to attract and hire physicians or others who may be in other areas, rural areas, are having a difficult time. and we need to be able to give them the tools that they need so that those hospital doors do not close and those residents in those communities do not suffer. And so this is a great bill. Thank you for your collaboration and for taking the amendment, and with that, would you like to close? Thank you so much. Again, you weren't here, but I did thank you for your help on this bill and for the amendments. I know it's not where we started, it's not where we wanted to be, but I think it is a targeted way to make sure that those hospitals that are struggling the most and with the patients who are struggling the most are going to have those doors stay open and the kind of reliability that physicians need to be able to get that direct employment with these district hospitals. So with that, respectfully request an aye vote. Thank you. And once we get a quorum, we will do that. Okay, thank you. So before we bring the next author up, just want to make an announcement that per the author, file number 24, AB 2353 by Assemblymember Pacheco has been pulled from today's agenda. We will now move to file item 6, AB 1148 by Assemblymember Sharp Collins. All right. Hello. You may begin. Thank you. Good afternoon, Madam Chair and Senators. I will be accepting the committee amendment. Every day, millions of Californians are exposed to harmful chemicals that increase the risk of cancer and other serious health conditions. Working families, low-income communities, and communities of color bear the greatest burden. They are more likely to live near sources of pollution, more likely to face cumulative environmental exposures, and less likely to have the resources to avoid them. For too long, the cost of doing business has been measured in profit, while the cost of the public health has been measured in lives. And when cancer touches our family, and as it has touched so many of ours, this issue is no longer abstract. That is why I am proud to present Assembly Bill 1148, the Safer Food Packaging Act. The bill prohibits two harmful chemicals commonly used in food packaging material, phthalates and dysphenols. California has already recognized the dangers of these chemicals posing. We banned phthalates from children's toys back in 2007 and from cosmetics back in 2020 and from IV bags in 2024 because we knew that they can harm humans health So if these chemicals are too dangerous for a child toy too dangerous for products that we put into our bodies and too dangerous for medical equipment used in hospitals, then we should ask ourselves one simple question. Why are they still allowed in materials that come into contact with food that we eat every single day? Assembly Bill 1148 closes that actual gap because preventing cancer will always be better than actually treating cancer. And let me be clear that this bill was not anti-business. Californians have always shown that protecting public health and growing our economy are not competing priorities. They go hand in hand. Assembly Bill 1148 simply says that Californians should not have to choose between three of their families and protecting their health. And when the science tells us that there is a preventable risk, then we have the responsibility to act on that preventable risk. With that, I will respectfully ask for an aye vote when that particular time comes for Assembly Bill 1148. But here to testify in support today is Dr. Jessica Lathrobich, who sits on Breast Cancer Prevention Partners, the advisory panel, and also Nancy Burmeyer, the director of program and policy of Breast Cancer Prevention Partners. I'll turn it over to my witnesses. Thank you. You will have a combined total of five minutes for your presentation. Great. Thank you for the opportunity to testify. and thank you, Assemblymember Sharp Collins, for your leadership on this important bill, AB 1148. I am Jessica Trowbridge. I have a Ph.D. in environmental health from UC Berkeley, and I'm a researcher at UCSF where I study environmental chemicals and their impact on our health. I am also a breast cancer survivor. I was diagnosed two years ago at the age of 45 with no family history or genetic markers for breast cancer. We know that the number of premenopausal breast cancer cases is increasing, and up to 90% of cases like mine are linked to environmental factors. AB 1148 focuses on bisphenols and phthalates. We are all exposed to these chemicals. More than 90% of people in the U.S. carry bisphenol A in their bodies, and other bisphenols are also widely detected in people. For orthophthalates, the percentage is near 100%. Studies show that these chemicals are harmful to our health. These chemicals are hormone disruptors and are linked to cancer. Thousands of studies show links to obesity, diabetes, cardiovascular disease, behavioral effects, aggression, impaired learning and memory, altered sperm count and quality, reduced testosterone, uterine fibroids, polycystic ovarian syndrome, breast cancer, and risk of miscarriage. BPA increases the growth of mammary tumors in lab animals and reduces the effectiveness of common chemotherapy medications. Orthophthalates are also hormone disruptors. Exposure has been linked to breast cancer, developmental issues, infertility, obesity, asthma, and problems with children's learning and behavior. Some phthalates have been shown in lab to increase growth of human breast cancer cells and decrease the efficacy of tamoxifen, a common breast cancer medication. Exposure to higher levels of some phthalates is associated with an increased risk of developing breast cancer, especially in premenopausal women. We know these chemicals leach from food packaging into our food, and we know that removing food packaging exposures lowers the level of these harmful chemicals in our bodies. So for these reasons, I urge you, I vote to eliminate these chemicals from our food packaging. Thank you. Good afternoon. Thank you for the opportunity to testify, and thank you, Assemblymember Sharp Collins, for your leadership on AB 1148, the Safer Food Packaging Act. Breast Cancer Prevention Partners is a proud co-sponsor, along with Environmental Working Group and CalPIRG. We are a science-based organization working to prevent breast cancer by reducing exposures to chemicals linked to disease. One in eight women will be diagnosed with breast cancer in her lifetime, and as you've just heard from Dr. Troubridge, women are getting breast cancer younger and younger. AB 1148 can make an important contribution to reducing the public's exposure to chemicals linked to cancer and other negative health impacts. As you've just heard how hazardous these chemicals are and why they don't belong in food packaging, in fact, this body has already prohibited the same chemicals in product categories, including toys, personal care and beauty products, and IV bags and tubing. Despite that, they are still legal in food packaging. Maine and Vermont have banned phthalates, and the European Union recently banned BPA and other hazardous bisphenols in food packaging. In fact, the EU will ban BPA on the external surface of food cans as of January 2028. Californians deserve the same protection. Last session, this legislature unanimously passed SB 1266, which ban the entire class of bisphenols in juvenile feeding and teething products. The enforcement provisions in AB 1148 are modeled after that bill. They give the Department of Toxic Substance Control the ability to enforce, as well as the flexibility to adjust the bans, if appropriate, based on new science. But let me reiterate what Dr. Probridge explained. The scientific evidence of harm from these chemicals is clear. Where we know there is harm and safer alternatives already exist, Consumers should not have to wait for a lengthy regulatory process to be protected. AB 1148 will give Californians the certainty and protection they need and deserve. I urge your aye vote. Thank you. If there's anyone else in the committee that would like to register their support for this bill, this is your time to come to the microphone, state your name, your organization, and your position only. Thank you. Good afternoon. Kelly McMillan on behalf of the American Academy of Pediatrics, California, in support. Thank you. Good afternoon. Susan Little with the Environmental Working Group in support and also on behalf of Center for Environmental Health, California Nurses for Environmental Health and Justice, Story of Stuff, Indivisible Marin, GMO Science, Friends Committee on Legislation of California, San Francisco Bay Physicians for Social Responsibility, National Stewardship Action Council, and California's Against Waste. Thank you. Thank you.

Thank you. Thank you. This is your time to come forward to the table. And you will have a combined total of five minutes, and you may begin. Good afternoon, Madam Chair, members of the committee. Tim Shestick with the American Chemistry Council. Thank you for the opportunity to testify today. I'd like to first start by thanking the author, her staff, and staff of the Senate Environmental Quality Committee for the dialogue and the ongoing work that resulted in the bill before you today. While these changes have addressed some of our and the coalition's concerns, we respectfully continue to have an opposed less amended position. We continue to believe that the regulatory framework and authority that rests with the Department of Toxic Substances Control provides the appropriate forum to assess the safety of food packaging materials establish appropriate threshold levels for intentionally added ingredients and if necessary, impose any sort of regulatory requirement. DTSC does have broad authority under the SCP program to identify chemical product combinations and if warranted, impose use restrictions, including restrictions on the amount or concentration of a chemical of concern or replacement chemicals that would be permitted in a product. As noted in the committee's analysis, the coalition has provided an alternative approach that would mandate that DTSC evaluate the use of these chemistries in food contact applications to determine whether it is necessary to establish a minimum safety threshold or some other regulatory response. And based on that assessment, require the department to initiate a formal rulemaking process that establishes those regulatory requirements. In recent years, the legislature has granted DTSC new resources, expanded its authority to compel manufacturers to provide information to help the department select priority products and authorize DTSC to implement a regulatory response more quickly. The department is currently implementing that authority. For these reasons, we feel that the program that was established at DTSC to undertake these complex scientific reviews and the department has been empowered with significant regulatory authority, we believe the legislature should utilize those resources. And for those reasons, we do respectfully remain opposed unless amended. Thank you. Madam Chair, members, Eloy Garcia for the International Bottled Water Association. I will be brief and just say I also appreciate all of the work that's gone into the bill, the continued work by the author and the sponsors over a two-year period really to hone in on the bill. We very much appreciate that. Continue to look for further refinement in terms of the definitions of durable materials. Durable materials, I think in the last policy committee hearing, we narrowed in on an exempted durable materials in a commercial kitchen application. and we'd like to give some consideration and thought to bottled water, three- and five-gallon that are really for home and office, which is not what the consumer buys and uses once, but what is commercially washed, commercially repurposed. But I'd like to ask you to give some consideration to that in the spirit of the last amendment. But thank you again for your consideration. Thank you. If there's anyone else that would like to register their opposition to the bill, please come forward to the microphone, state your name, your organization, and your position. Elizabeth Esquivel of the California Manufacturers and Technology Association, also expressing due gratitude for the amendments that the author has taken over the two years. We do share our concerns regarding the regulatory authority from DTSC, the potential of what that would look like, but I'm very happy and appreciative for the amendments that have been taken. Thank you. Thank you. Dennis Albionni with Consumer Brands Association. Again, we greatly appreciate all the work that's been going into this. And at this point, still opposed unless amended. Still working on the last few details. Thank you. Thank you. Sorry. Sarah Polamute, the California Retailers Association. We actually just joined the opposed unless amended, but we will be having conversations with the authors. So thank you. Thank you. Edwin Bourbon on behalf of AmeriPen, the American Institute for Packaging and the Environment, as well as the Flexible Packaging Association. Opposed unless amended. Thank you. Thank you. Ryan Spencer with the American College of OBGYNs, Jish9, and apologies. I was not a committee but we actually support the measure Thank you Thank you Seeing no one else that would like to register their opposition we bring it back to committee I want to thank you, Assemblymember Sharp Collins, for working on this very important bill. And with that, would you like to close? Yes, I just want to thank you as well, along with my sponsors and everyone who actually came in to testify in support, but also the opposition for working with me on this particular bill. This bill is extremely important to me as I am a daughter of a two-time breast cancer survivor, and actually right now my god sister is in surgery right now getting a double mastectomy. And so this is something that's very important to me, and I believe today we do have the opportunity to reduce the unnecessary exposure to harmful chemicals and to prevent disease before it actually starts. And I'm a strong believer that California will continue to make sure that health is going to be first. So with that, thank you again, Madam Chair and Senators. I respectfully ask for your aye vote for this bill. Thank you, Assemblymember, and thank you to those who came to speak in support. Once we get a quorum, we will be able to take a motion on this bill. Thank you. I see file item 16, AB 1825, Assemblymember Krell. And you may begin when you're ready. Thank you. Good afternoon, Madam Chair and Senators. Thanks for having me today in Senate Health. I'm here to present Assembly Bill 1825. This is an important bill that helps streamline both the front end and the back end of our offenders with mental health disorders program. It does so by ensuring that this targeted population both receives the evaluation and treatment that they need while they're incarcerated, but also when they come out of incarceration and into the community that they receive Medi-Cal services and continued support. With me to testify for this bill is Dr. Erin Meyer from the California Association of Psychiatrists and also Kim Stone from the District Attorneys Association. Thank you. You will have a combined total of five minutes for your presentation. Good afternoon. Chair Dr. Weber Pearson, members of the committee, Aaron Meyer, Associate Clinical Professor of Psychiatry. Is the mic not on? Hello? Okay. Thanks. Aaron Meyer, Associate Clinical Professor of Psychiatry at University of California, San Diego, speaking on behalf of the California State Association of Psychiatrists, proud sponsor of Assembly Bill 1825. As a practicing psychiatrist, I see firsthand how fragile transitions are in California's public behavioral health system and what happens when they fail. Patients with the highest needs too often fall through administrative gaps rather than clinical ones. AB 1825 closes one of those gaps. Today, individuals classified as offenders with mental health disorders or OMHDs are treated differently based solely on where they are receiving treatment. Those in prisons and jails are eligible for CalAIM justice-involved reentry services. Those receiving treatment in state hospitals are not. The assumption has been that these individuals will return to custody before release, but that is not always what happens. When an OMHD classification is revoked by a superior court judge, that individual must be released within 30 days. Those 30 days are critical. They are the window in which effective coordination determines whether someone successfully transitions to community treatment or deteriorates These are individuals with severe mental illness often with a history of violence whom the Department of State Hospitals has identified as being at elevated risk of reoffending when released directly to the community. AB 1825 ensures that during this narrow but critical period, treatment recommendations are communicated to the county behavioral health system, the system responsible for providing ongoing care to these individuals. It is a simple, common-sense fix. It strengthens continuity of care, improves coordination between state and county systems, and promotes public safety. I respectfully ask for your aye vote on AB 1825. Good afternoon, Chair and members. Kim Stone on behalf of the California District Attorneys Association in support. This bill is supported by both public safety and health groups. and the District Attorney's Association is pleased to support it because it promotes public safety by ensuring that individuals with severe mental health disorders receive the treatment and supervision that they need. This bill establishes clear evidence-based factors for evaluating the dangerousness of offenders with mental health disorders, including history of violence, threats, treatment compliance, and forensic hospital commitment. We support when individuals are released via court order, they need a plan. Since current law provides no such exit plan requirement, when the OMHD classification is reversed, this bill is necessary. Planning supports both public safety and the individual needing treatment. We support closing the gap in current law that leaves patients in state hospitals without the option to enroll in Medi-Cal 90 days prior to release the way other incarcerated patients can. We therefore urge your aye vote. Thank you. If there's anyone else who would like to register their support for this bill, please come to the microphone, state your name, your organization, and your position. Angela Hill with the California Medical Association in support. Thank you. Seeing no one else, I would like to register their support. If there's anyone who would like to speak as lead opposition, this is your time to come to the table. Seeing no one, if anyone would like to register their opposition, this is your time to come forward to the microphone, state your name, your organization, and your position. Seeing no one, we'll now bring it back to the committee. Move the bill. Thank you, Assemblymember, for bringing this bill forward. You have a motion at the appropriate time once we get a quorum by Senator Grove, but would you like to close? Thank you. I respectfully ask for your aye vote. Thank you. And at the appropriate time, we will take up that motion. We will move to file item 22, AB 2282, by Assemblymember Alanis, and thank Assemblymember Gonzalez, because I know you have been here the entire time. Thank you for letting me go ahead. Yes. We were just talking about that. We did a... Yes. You may begin when you're ready. Well, thank you, Madam Chair and committee members. AB 2282 addresses the lack of access to emergency health care services in the city of Patterson and surrounding communities in my district. This bill would require the Department of Public Health, the CDP, to issue a waiver to a publicly owned and operated hospital to operate a rural emergency stabilization care unit in Patterson while a permanent hospital is being built. My office has worked with stakeholders on amendments to make sure this facility would be properly licensed and compliant with existing standards for patient health and safety. Right now, residents of Patterson and the surrounding areas must travel over 20 miles to reach the nearest full-service hospital or trauma center, which has created significant barriers to accessing health care. AB 2282 is a temporary solution that would allow patients to be treated for emergency health care conditions until a permanent hospital is constructed. The waiver authorized by this bill would expire after 10 years or after a general acute care hospital is operational. This bill is sponsored by the Del Puerto Health Care District, and with me today I have Dr. Karen Fries, the CEO of Del Puerto Health Care District, And also I have, oh, actually I have a lot of people up here. I'll let them all go. Go ahead. With that, I'll go over there. All right. Whoever is presenting, I think there's two presenters. You'll have a total of five minutes to present. Thank you very much. Chair Weber Pearson and senators, thank you for having us this afternoon. Del Puerto Health Care District, as the Assemblymember mentioned, is governed by a publicly elected board, and we have served the west side of Stanislaus County since 1946. I'm here to respectfully ask for your aye vote on AB 2282. AB 2282 is a critical temporary safety bridge for Patterson while we build a permanent health facility care system for our community needs. Patterson is a growing rural community with no local emergency room. The nearest hospitals are roughly 19 to 21 miles away, which is 30 minutes or more without traffic. That drive is affected by limited roadways, agricultural and freight traffic, rail crossings, Highway 33 congestion, fog, and flooding. For a working family, a farm worker, a senior, or a child in crisis, those minutes matter. AB 22 authorizes a rural emergency stabilization care unit, a rescue, to provide medical screening, stabilization, and triage close to home. The rescue would include board-certified emergency physicians, hospital-level staffing, on-site nursing, pharmacy, lab and radiology support, and EMTALA protections. Patients who need a higher level of care would be stabilized and transferred appropriately. This is not a substitute for the hospital that we are working to build. It is a bridge to get us there. The district is developing a 38.5-acre health care campus that includes an ambulance center, a combined physical and mental health clinic, senior living, which would begin in 2032, a medical office building, and a hospital that would be open between 2035 and 2040. But our community cannot wait until 2040 for local emergency care. Patterson is predominantly working class with significant medical enrollment. These residents do not have easy alternatives for emergency care when it is far away. AB 2282 is narrow, accountable, time-limited, and local. It gives our community a safer option while a permanent health system is built. I respectfully ask for your aye vote. Thank you. Kelly LaRue here with Resilient Advocacy on behalf of Jim Whitworth, the clinical education manager at Patterson District Ambulance. He couldn't be here today. He had to cover a shift last minute, so I'd like to share his testimony. I want to give this committee a clear picture of what emergency response looks like on the ground in our community When we get a call in Patterson we respond we stabilize and we drive at a minimum 25 to 30 minutes to the nearest emergency department But transport time is only part of the equation. Once we arrive at the receiving hospital emergency room, we typically wait 20 to 30 minutes, sometimes longer, to transfer patients to their care. One call takes our unit offline and out of our response area for two hours or longer. If a second emergency happens during that window, that patient waits longer for help. Statewide, 85% of emergency department visits do not result in a hospital admission, meaning a significant share of the patients we transport could be appropriately evaluated and stabilized closer to home. I've helped stabilize, not me personally, but Jim, has helped stabilize hundreds of patients, but there are life-saving interventions we simply cannot provide in the back of an ambulance. A local center would allow patients to begin receiving care right here in Patterson rather than 30 minutes away. AB 2282 gives Del Puerto Health Care District the tool to provide that care while the full hospital is being completed. Having these additional resources close to home will save lives. Our community deserves that. I respectfully ask your aye vote on AB 2282 on behalf of Jim. Thank you. Thank you. If there's anyone else that would like to register their support for this bill, this is your time to come forward to the microphone. state your name, your organization, and your position only. Seeing no one, if there's anyone who would like to register their opposition to this bill, as a lead witness, this is your time to come forward to the table. Thank you. You may begin.

that would like to register their opposition to this bill, this is your time to come forward, state your name, your organization, and your position only. Seeing none, we'll bring it back to the committee. Senator Caballero. Assemblymember, I appreciate you bringing this bill forward. I used to represent Patterson, so, you know, I'm near and dear to my heart. But the other part of the equation is that if you're traveling from Southern California to Northern California, the only community you hit that's on Highway 5 or the freeway is Patterson, the only city. And you're absolutely right. The distance to another medical facility is significant. It's rare that the traffic is not bad because of all the commuters that are coming from all over the place, and you wouldn't want to end up in a traffic accident or need emergency medical services there. It's pretty unbelievable that we don't have a hospital facility, and I know that's down the road. And so I'm going to support your bill today, and I'd like to be added as a co-author if you're so inclined. Thank you, please. And that was actually part of my closing with high five. Good. Well, now you don't need to do it. That's all I'm saying. But thank you for bringing this because this is really critically important. Thank you. Senator Grove. Thank you. Thank you, Madam Chair. Thank you for bringing this bill forward. I, too, represent a lot of rural communities that have very limited access to health care. I applaud the chair for helping us with financially distressed hospitals and my colleague that just spoke because she was the champion of financially distressed hospitals. I don't think either one of us came up here to support financially addressed hospitals, but we found ourselves in that situation when our hospital's gotten such an emergency situation. I, too, travel I-5. You know, I complain to these people all the time. I have been here since 2010, the longest-serving member, and I still don't have a flight from Bakersfield to Sacramento, and I have to drive I-5 up and I-5 back, and Patterson is the best place to stop. They have good Chinese food, clean restrooms, and it's easy access on and off the freeway. I can't imagine being in a place like Patterson I can because we have Ridgecrest which when the hospital was going to close it was two and a half hours down at Canyon Road or over to Lancaster 45 minutes if you were lucky not to hit traffic and so I applaud you for bringing this forward I too would like to be out at a co-author and I appreciate the concerns but that's like throwing the baby out with the bath water for what my mom would say or perfect being in, you know, you want the perfect and we're going after the good because it's closer and more attainable to get at this point and then work on hospital later. So thank you, sir. And I'll move the bill when appropriate. Thank you. Thank you. Senator Menjafar. I'm going to deviate from the previous comments that were just shared by my colleagues. Last year this body heard a study bill on this issue and it didn't get out of committee. maybe it's different because that was a for hospital and this is a different kind of system But the concerns are still applied here today And I just want to know if the concern is which it is I agree the lack of access to health care in rural areas I do want to remind this committee and the body that just a couple of days ago, we took in from the federal government $233.6 million to address the California Rural Health Transformation Program that is actually going to look to within the jurisdiction and making sure it's safe for our patients. to close the gaps in rural communities to address the very same thing you're looking to address. And it's not going to stand up a freestanding ED that could potentially put patients at harm because of the confusion it's going to cause, thinking that they're going somewhere that it's not going to have intensive care services. And then even though they just drove to this freestanding ED, are going to now have to be transported to a different hospital or to an actual hospital. So I feel like if the goal is to address the gaps, we just got the funding to do that. There are going to be rural hospitals that are going to come together to close the gaps in rural areas. Why not wait for that to happen? That will be done before this hospital is being built in potentially 2040. That is not a guarantee. That just says that it will be built in 2040. It's not a guarantee it will be. Why not do that and wait for that versus standing a FED? So, as you pointed out, I believe that the difference between the two bills is, one, we were already going to have a hospital being built, whereas that study bill didn't have a hospital that was going to come behind it. The other thing is, why would I want to wait when I know I could save lives? In my prior job, when we weren't able to provide services because that was brought up with the statements that Kelly brought up, imagine being the family that's waiting for the medical services to know that they're on the other side of the county and we're waiting just to have something that's done that's being funded by the federal government. And right now, I don't really see government really pushing things as quick as we want them to do. So if I can work on it now, I'd rather do it now than wait. So this funding is to focus on it now. And verbatim from the budget trailer is it's a vision of a connecting and resilient rural health system, helping ensure real Californians can access timely person-centered care closer to home. So that's not in the future. That funding was associated already, hundreds of millions of dollars. that's going to be working on what you're looking to do now, but ensuring that patient care is at the center of that. And confusion, again, like that's a big part where you're going to have someone potentially with a TBI go to this FED knowing that it's not a real ER. That could put them at jeopardy. There's a long list of things that people can confuse. I know there is LEMSA protections that at least ambulances won't be routed there. I understand that part, but in terms of just a regular person that coming to the ED with an ambulance, there's going to be a lot of confusion for these patients. So we already have confusion like that in Stanislaus County. We had an existing hospital that was on Scenic Drive that we've actually had people drop people off in front of, like gang members after a shooting drop them off thinking they're going to get worked on. So it is going to happen regardless, but to the problems that I know of now, and unless you guys want to add to it, I know those that can take care of the problems that we can in that facility will be brought there, and I know that the ambulances are going to know what they can and can't do. As far as somebody just coming to show up, I can't answer 100% on that question, but I can also, if it's an 80-20 issue, I'd rather take care of the 80 as opposed to the 20. Sure. If that problem already exists, I don't understand why. We'd want to increase that problem of people being dropped off at places where they shouldn't be dropped off of, if that's already a problem. My second question is the conversation around the pay, the cost for the patient. This is a glorified urgent care, but yet the patients are going to be charged ER costs versus what they could potentially get done at urgent care. also creating added financial strains to individuals who won't know that that's the kind of treatment they can get at an urgent care. So how do you then protect, given the cost of health care, patients that they're now going to – because a lot of people use ERs as their main source of care. They're going to go to this now when, in fact, they could have gotten a lot of that care, an urgent care that I know Patterson has. Well, again, I think that's going to be a problem everywhere you go, regardless if this building's there or not. I've actually been in an ER to have something taken care of that I knew urgent care could have did, but urgent care couldn't do the x-rays that I needed. So I sat in there also. So they're either going to go sit in one in Modesto for that and not have to worry about a true emergency, or they're going to have to go sit in the one that we're trying to make in Patterson. And if you guys want to get more technical on that, if you don't mind, through the chair. You may respond. Thank you very much. So we are expanding our rural health clinic, which will also have a community mental health clinic, and those urgent care hours would be able to address the majority of those cases. So it would be an alternate situation. We would also conduct within the ED a triage program that would put people towards the appropriate level of care. So you're saying if they go to this FAD? RHC. Oh, the rescue unit. No, if a person, if a patient went to, should this bill pass, they went to the FAD, the freestanding emergency department. that went there, you are envisioning a triage where, hey, you don't need to be seen here. Can you leave and go to the urgent care? Correctly. Yes. Isn't there a little bit of liability there? I believe the patient would still need to be seen and assessed before you let the patient go. Absolutely. That's not to mention the triage wouldn't occur. but the process is that the triage is always looking for the appropriate level of care for the patient. If we live that out, I am there. I'm going to be like, see me now, not knowing that I'm going to have to pay more. I would be pissed off if I've got triage, and in the moment they're like, okay, go to a different place. Now I'm going to get a bill here, I'm going to get a bill there, or I refuse to go to a different place because I just wait in a waiting room for so long to be seen here, why would I leave? I'm wrong. I'd love some clarity. Thank you. So a couple of mechanics around the bill. So, yes, absolutely. If a patient presented, they would have to be evaluated and then triaged. Whether they are admitted into or transferred to another hospital would be determined by the clinician that's treating them. However, we're looking at a situation where we're dealing with essentially what is a consolidated license and a partnership between public entities. And so to your point, are you going to get two bills if you are then treated at the RHC? No, not necessarily. Right. Like, again, and we were very thoughtful in the language of the bill, is that it is really meant to be public entities operating this for the good of the consumer. And so, again, we've we've really tried through the language and happy to walk through, you know, in finer detail. But we are really attempting to make sure that this is not a freestanding emergency department as has been seen or mentioned in other states It not meant to be exploitative or to have there be any sort of double billing If a consumer seeks their health care at a health care district, we want to ensure they are billed appropriately for where they receive that service, whether that be the RHC or the FED. The bill actually has a waiver process under a general acute care hospital license, so we are limited in how we can bill for various services. It's not the way that freestanding emergency departments traditionally bill under CMS guidelines because it's actually a waiver for a general acute care hospital. Okay. My last question, Madam Chair, is regarding do you envision having your own ALS ambulance to transport all the patients that need intensive care or are you going to be relying on 911 to transport all the patients that are going to be coming in impacting access to 911 given the fact that they have to be transported to a real hospital? So currently Del Puerto Health Care District already participates in the 911 system. We provide ambulance services that are transporting across the county currently. We will be expanding our services to include BLS units as well as ALS units that would be able to handle those inter-facility transfers. Okay, so you have your own set? We do. Okay. Correct. Well, I want to thank you very much, Assemblymember, for bringing this bill forward and for those who have come to speak in both support and opposition and for the comments made from my colleagues. We're hearing this bill today because we don't have a policy here in the Senate to hold bills. We're not hearing it because I support it. I completely understand the difficulties in the rural areas and areas where we do not have hospitals. I would recommend that maybe you think about taking Senator Menjavar's suggestion of looking into some of the recent funds to kind of build the hospitals. As a physician, as a surgeon, understanding that this facility does not have an operating room. And when people see emergency room, they believe that they can go there for any and everything. So my concern is for the family that comes and drives there and waits in the emergency room for 30, 40 minutes, 50 minutes to be seen. Seen by a doctor, is in the waiting, is in the room. they are with abdominal pain, ultimately ends up having an api that ruptures. All of that time that they've been there, they're now going to have to go somewhere that can actually surgically manage that. We're talking about patient safety. I have unfortunately seen many instances where patients come to the emergency room abdominal pain, positive pregnancy test. They wait to be seen. And after a while, that ectopic pregnancy ruptures. And that's when I am called to urgently take that patient back to the operating room because she's bleeding in her belly. This freestanding emergency room would not have the ability to truly care for all emergencies and what it would do is delay the care for those who need those other types of emergencies that you cannot manage in a freestanding emergency room. My hope is that you all get a, that we build a hospital in that area that really truly serves all of the needs of the patients in that area. But I think, to Senator Menjavar's point, when people see emergency room, they believe that this is a place where they can truly get all of the care for all of the emergencies that they may need. And so for that reason, I will not be supporting the bill today, but appreciate the fact that you have brought it forward and that you are looking out for your community. And with that, would you like to close? Yes, thank you. Well, I don't have to skip the I-5 part, but, yes, if people are driving through, They have no idea that they don't have a hospital anywhere near. As far as those with real-life problems around Patterson, for me, working the west side also, if I can help, again, 80% of those who don't have the extreme emergency like you talked about, we can at least get them help and then be able to have those ambulances be able to take them to the hospitals that do have the operating room. Right now, this is just alleviating some of the pressure that is going on on that side of the county, which is growing. Patterson is growing. A lot of the Bay Area are moving into Patterson. They're almost surpassing the next city next to them. It's great that they're growing, but because they're growing, we need to continue to make sure we're providing the services. I never thought as a cop that I would ever be here one day to be able to try and help that community by doing this legislatively, but I have to do it. I'm here, so that's what I'm trying to do. So with that, I ask for your high vote. Thank you, and Senator Grove has made the motion, and once we get a quorum, we'll be able to actually move on that motion. Thank you. Now we will move back in the file to file item number 9, AB 1540 by Assemblymember Gonzalez. And you may proceed when you are ready. Sure. Point of personal privilege. Happy early birthday, Madam Chair. Thank you so much. I know. That wasn't me. Okay. Thank you, Madam Chair. Thank you for the opportunity to present with you today. I also want to begin by expressing my appreciation to the chair and committee staff for working with my office on this bill. Suicide prevention, public health responsibility, the kind that shouldn't shift depending on who's in office. And when a young person finds the courage to ask for help when they are at their lowest point possible, the worst they can do is ignore them. But that's exactly what Trump did. Last year on July 17, federal funding for the 988 LGBTQ plus crisis was cut. And just like that, a lifeline that thousands of kids depended on was gone. Why? We do not know. You see, the CDC reports that LGBTQ plus youth attempt suicide at almost a triple the rate compared to their peers. And I know everyone here can relate to that feeling, that feeling of darkness that overwhelms your mind, that feeling of helplessness. But that pressure is real, and now our LGBTQ plus youth have now nowhere else to turn. Not because they are broken, but because the system designed to uplift them has been erased. AB 1540 is about restoring a lifeline. It reinstates the press 3 option within the 9-8 system so that when someone reaches out in crisis, they can be connected to a trained counselor who understand the unique challenges LGBTQ plus youth face. And restoring this service means restoring something simple but powerful, the chance for someone on the other end of the line to say you not alone stay with me Sometimes the difference between tragedy and tomorrow is just one voice picking up that phone call AB 1540 helps to make sure that voice is there. This afternoon, primary witnesses in support with me to highlight the impact of the bills, Bridget McCarthy, mother of Riley, an advocacy with the American Foundation with Suicide Prevention, and we also have Diva Sheev, Senior Policy Advocate for California Alliance of Child and Family Services to act as a technical support witness. Thank you. You will have a combined total of five minutes for your presentation. Hello. Hello. Good afternoon. My name is Divya Shiv with the California Alliance of Child and Family Services.

Thank you, Madam Chair and committee members. My name is Bridget McCarthy and I'm here on behalf of the American Foundation for Suicide Prevention, the nation's largest private funder of suicide prevention research, and I'm here to urge an eye vote on AB 1540. But more importantly, I'm here as a mother. In September 2020, just 12 days after his 16th birthday, I lost my amazing son to suicide. His birthday balloons were still in his room, and that's an image I carry with me every day. And that's why I'm here. I'm here for Riley and Bella and David and Matthew and Dajon and Henry and the many others we have lost and the many mothers who will no longer buy birthday balloons. After we lost Riley we learned that in the middle of a crisis he had reached out. He had texted a gay friend hoping for a connection that never came. At that time there was no 988, there was no option 3, no dedicated line where LGBTQ plus youth could speak to someone who understands their world. We know that a veteran in crisis looks for a fellow soldier, that's why we have option 2. We know that the person, in the same way an LGBTQ child needs to know that the person on the other end of the line truly sees them. And that used to be option three. Last year, the federal government eliminated the Press 3 LGBTQ sub-network of 988, cutting off a critical lifeline. This was not a niche service. It handled 73,000 calls from California in the year prior. With suicide attempt rates amongst trans youth more than four times their peers, we cannot afford this gap. AB 1540 restores that lifeline. It ensures that when a young person reaches out, someone who understands will answer. My son was reaching out into the dark. He could not find a hand that felt familiar. And that is the heartbreak I live with. It's a heartbreak no parent should endure. And so again for Riley and every child still reaching out, please support reinstating option 3 and support AB 1540 because this legislation is that hand in the dark. Thank you so much. Thank you. If there's anyone else who'd like to register their support, please come to the microphone, state your name, your organization, and your position only. Thank you. Angela Hill with the California Medical Association in support. Thank you. Angela Pontus with Planned Parenthood Affiliates of California in support. Thank you. Malik Bynum with the County Behavioral Health Directors Association in proud support. Thank you. Thank you. Andy Liebenbaum County of Los Angeles in strong support. Mary Creasy Allen for Safe Schools in support. Isabella Argueta with the Health Officers Association of California in support. Dominique Santiago for the Commission for Behavioral Health in support. Thank you. Mary Moyle and I'm here for the following PFLAG chapters. Sacramento, Oakland, San Jose Peninsula, and San Ramon Danville. We urge an aye vote. Thank you. Brian Ricks of the Los Angeles Unified School District in support. Good afternoon. Melina Manictis on behalf of the Lieutenant Governor, Eleni Kunalakis, in support. Nora Angelis with Children Now in support. Afternoon. Kelly Macmillan on behalf of the California Association of Marriage and Family Therapists and the American Academy of Pediatrics, California, in support. Good afternoon. Dylan Elliott on behalf of the City of West Hollywood, the County of Humboldt, the California State Association of Psychiatrists, and the California Academy of Child and Adolescent Psychiatry, all in very strong support. Aston George Williams with the California LGBTQ Health and Human Services Network, in strong support. Francisco Arnells with the University of California Student Association, in strong support. Yancy Garcia-Montez, also on behalf of the University of California Student Association, and we strongly support this bill. Thank you. Veda Diptaman, also involved with the University of California Student Association, in strong support. Kids should not feel that they're better off dead than gay. Therefore, we strongly support this bill. Kelly Brooks, on behalf of the Santa Clara County Board of Supervisors, here in support. Thank you. Sarah Weber with the Drug Policy Alliance in support, also registering support on behalf of the Sacramento LGBT Community Center. Thank you. Thank you. Kylie Lindelli with the AAPI Queer Joy Coalition and Asian Americans Advancing Justice Southern California in support. Thank you. McLean Rosansky with the Alameda County Office of Education in support. Thank you. Thank you. Cal Gun Violence Prevention in support. Thank you. Thank you Adam Kegwin on behalf of Alliance College Ready Public Schools and California LULAC in support Thank you Anthony Gedebaimena Mental Health America of California in support Thank you. Elijah Joseph, LGBTQ plus inclusivity, visibility, and empowerment in support. Thank you. Thank you. Ryan Safarian on behalf of Equality California National Center for Youth Law, Jewish Center for Justice, Seneca Family of Agencies, California Association of Social Rehabilitation Agencies, and Culver City Democrats, all in support. Thank you. Thank you. Seeing no others who would like to speak in support, we'll now open it up for anyone who would like to speak as lead opposition. Please come to the table. You will have a combined total of five minutes for your presentation. Good afternoon. Lisa Disbro, is it on? Okay. Good afternoon, Lisa Disbro. I represent our duty and informed parents of Contra Costa County. I'm a mother. I'm a nana. I'm nana banana. And I cannot imagine the pain that Ms. McCarthy carries due to the loss of Riley. Our children are supposed to outlive us. Riley deserved more time and to grow up. Riley's tragic, unnatural ending was avoidable. and that truth makes it harder to bear. But I take issue with the insinuation that had Riley been unable to speak with a Trevor Project counselor trained to affirm that her body was the problem rather than the pain underneath it, that Riley would not have taken her life that day. From Ms. McCarthy's own account, Riley was inquisitive, artsy, quirky, and most of all, deeply loved. Riley had many of the characteristics of the new cohort of girls who adopt a transgender identity. Her mother did what she was told. She affirmed Riley as a boy. The gender industry repeats relentlessly. I'm sorry. I'm sorry. If we can. Did you know Riley personally? Yes or no? It's a simple yes or no. That's not a fair question. No, I'm asking because you cannot speak on someone else's child. I have heard her testimony many times. It doesn't matter what you've heard. Did you know Riley? It's a simple yes or no. I don't know her, but I know that she was loved by her mother. Excuse me. Please do not try to over talk me. Please talk about the bill and your opposition to the bill. Do not speak about someone else's child that you have never met and is not here to defend themselves. Riley was affirmed as a boy, correct? Ma I am going to give you one more chance to talk about your opposition to this bill and not about Riley If you cannot do that then we will move to the next person Thank you Continue. The gender industry repeats relentlessly that you should affirm your child's rejection of their natural, authentic body. if the affirmation does not come that the consequence will be the child will die. This has been told to many, many children, and that's of record. You know that this is not true. You heard the proof recently from the ACLU's own attorney, a trans-identified female herself, who admitted before the Supreme Court that the transition does not prevent suicide. Riley is faultless, in my opinion, but the legislature is not. Thank you. Your testimony is complete. We will now move to the next witness. You may begin. Appreciate it. Chair and members, I oppose AB 1540. Every young person experiencing a mental health crisis deserves compassionate, professional, and evidence-based support. My concern is not with helping vulnerable youth. My concern is with embedding a private advocacy organization, the Trevor Project, into California's crisis response system. The 988 system was created to provide neutral, comprehensive mental health services for all Californians. By elevating a specific outside organization within that system, AB 1540 risks blurring the line between crisis intervention and advocacy. Californians come from many backgrounds and hold a wide range of beliefs. State-supported crisis services should remain focused on immediate safety, mental health stabilization, and connect to local care, not on promoting the perspective of any particular nonprofit organization. The bill also raises accountability concerns. Public crisis services should be overseen directly by state agencies and licensed mental health professionals accountable to us California taxpayers. When a private organization becomes a preferred or designated partner, citizens have less transparency into training standards, policies, and decision-making processes. In addition, California already operates a statewide 988 system intended to serve everyone. Rather than creating special pathways connected to a particular organization, we should invest in strengthening crisis services for all youth regardless of their identity, background, or beliefs. AB 1540 moves California toward reliance on a private advocacy group rather than maintaining a neutral publicly accountable crisis response system. For these reasons, I, Paul Everts, respectfully urge no. Thank you, and thank you for focusing on the bill at hand. If there's anyone else in the audience that would like to register their opposition to this bill, please come forward, state your name, your organization, and your position. on behalf of the sfe alliance and the california moms for liberty we are in opposition thank you seeing no further individuals that would like to register their opposition we bring it back to the committee senator grove thank you madam chair um i just going to say something that i hope I can get through I was deeply grieved by what your comments were

Senator Menjola.

Thank you, Senator Grove. Thank you. So just a quick education, and not that everybody needs this.

And can you make a comment on your referencing the research that Trevor Project does?

Yes or no?

Sure, go right ahead.

Okay. I appreciate it.

Thank you.

And just a point of clarification, Madam Chair, you have to have a specific call center, in this case a nonprofit or a group, that specializes in this, and Trevor Project is not a 988-designated center.

So I think this whole discussion about the Trevor Project is not correct.

I want to thank the Assemblymember for bringing this bill forward. it is extremely important. We do have a crisis, and there is data that shows the importance of peer-to-peer counseling, not just any individual, but actually peer-to-peer counseling, especially with some of our high-risk groups. And we know that our LGBTQ community is at high risk based on data, not only from the Trevor Project, but from other sources as well. So I want to especially thank your witness for not only coming and being very vulnerable and sharing a very painful story I am also a mother and I cannot imagine what you went through but also cannot imagine what you go through every time you have to relive it by telling the story. The amount of power that you have and stamina to sit there and listen to someone and say some very interesting things about someone who they do not know, but you knew very intimately, you gave birth to. You are more restrained than I would have been. So thank you so much for that, and I apologize that you had to endure that in my committee.

Thank you, Madam Chair, and thank you so much for you and I made eye contact on that, and thank you, Bridget, for being here. You and I have grown a friendship over the last couple of years, specifically in the fact that last year, and thank you to this chair and thank you to members of this committee, AB 727, today the law goes into effect requiring ID cards in California schools to include the LGBTQI plus suicide hotline. And so today, you and I have been through a journey together, and again, I want to echo and thank the chair for her comments today, and to Senator Grove and Senator Menjivar for all of your leadership and your work in addressing this very important and crucial issue here for many of us. This bill is not easy, and we know that. And I've read the opposition letters. We've heard the opposition, the ones claiming this bill is about ideology or politics or some kind of an agenda, and it's just complete offense. you know, offense and utilizing another group that's here to help as your foundation of an argument that that is simply doesn't exist. And let's be clear about what this bill is actually about. It's a phone call. It's a young person alone in their room staring at the ceiling at two in the morning wondering if anyone in the world understands them enough to keep them alive just for one more day. I've shared this story in another committee. I've shared it on the floor. And, you know, Bridget knows this and so does my team. A friend of mine earlier in the year had reached out to the 988 helpline, got that help that they needed, their life was saved. Several months later, unfortunately, they took their life. And I don't know if necessarily they made that call and someone didn't answer that, but unfortunately they took their life. And we just recently buried that individual. And I want to read on the back of their memorial card what it says. And I think this is attributed to somewhere else, but it doesn't have the name on here of the author. But it says, Don't grieve for me, for now I'm free. I turned my back and I left it all. I could not stay another day to laugh, to love, to work, to play. Tasks left undone must stay that way. I found that peace at the close of the day. If my parting has left a void, then fill it with remembering joy. A friendship shared, a laugh, a kiss, ah yes, these things I too will miss. Be not buried or burned with times of sorrow. I wish you the sunshine for tomorrow. My life's been full, I savored much, good friends, good times, and a loved one's touch. Perhaps my time seemed all too brief. Don't lengthen it now with undue grief. Lift up your heart. And when they finally find the courage to reach out, we should make sure that someone on the other end of the line knows how to help them. And with that, and Bridget, in honor of Riley, committee members, I respectfully ask for your aye vote.

Switching gears, Madam Chair. Thank you. Thank you, Madam Chair and members, for the opportunity to speak to you today. I'm proud to present AB 1679, which creates a temporary commercial activation permit framework for local governments to allow PAPA businesses to operate for 120 days. I want to begin by expressing my appreciation to the chair and the committee staff for their work on this bill I also want to thank the stakeholders who contributed to improving the bill and the opposition who have taken a neutral stance In my district and areas like downtown Los Angeles Chinatown Koreatown Little Tokyo Boyle Heights and many of our downtowns we see storefronts after storefronts boarded up and vacant. COVID-19 had permit impacts on the retail and restaurant sectors, forcing countless small businesses to close, and high costs for entry makes business prospects few and far between. Papa businesses are a proven effective way to activate these vacant spaces and give small businesses the opportunity to boost. Imagine a traveling restaurant, a wedding dress trunk show, or a local artist showing their new collection. Moving into these abandoned storefronts, due to this temporary nature, people are more inclined to come out and shop at these innovative stores. Papa businesses drive local events, foot traffic, sales, tax, and positive spillover effects to nearby businesses. However, they are struggling to legally operate on our current permitting structure. Many temporary permits only last a week, and the only other alternative is to apply permit occupancy. For small businesses opening a temporary in multiple cities in a single year, this is an extreme cost. For example, in L.A., it can range from $80 to $184 for a temporary food facility permit. The permit restaurant permit process will cost exponentially more. Popos have been shut down because they lack a permanent permit or extensive renovations, even if they're considered a low-risk business. After trying to pursue these costly permanent permits, many businesses close down, abandon the space, leaving it vacant once again. Current requirements of the pop-ups are disproportionate to the scale of duration of your use. AB 1679 addresses the issues requiring local governments to create new temporary commercial activation authorization, which will be consistent limited low-risk framework to activate storefronts across our state. Here to testify on this bill are Eddie Navarrete, who represents the sponsor of the bill and the Independent Hospitality Coalition, and Malik Nemo, who owns Twin Snakes Coffee, right here in Sacramento. I know. Take it away.

My name is Eddie Navarrete. I am the President of the Independent Hospitality Coalition. I represent iDiverse Network of Small Businesses across L.A. County and California today. Across California, we are facing a growing challenge that can be seen in nearly every community, rising commercial vacancies and empty storefronts that are sitting idle for months, sometimes years. In Los Angeles alone, retail vacancies have climbed to some of its highest levels in over a decade. These vacancies are not just economic issues. They have real impacts to our neighborhoods. Empty storefronts reduce foot traffic, discourage new investment, and create a ripple effect where surrounding businesses struggle to survive. When one space goes dark, it often leads to others following, weakening entire commercial corridors that communities depend on. At the same time, we have no shortage of entrepreneurs ready to open for business. What they lack is access. The cost and complexity of permanent construction has pushed too many operators out before they open. For many small businesses, the requirement to commit a full build-out upfront is simply not achievable in today's economic climate. AB 1679 provides a practical solution by creating a pathway for temporary commercial activations of vacant storefronts. This allows small businesses to enter spaces with lower upfront costs, test concepts, and build towards permanence without taking on overwhelming financial risk. This includes a wide range of businesses from yoga studios to art galleries. It could be a workout studio. It could be a tea shop, a coffee shop. It could be the businesses that we still have yet to discover. At its core, this is about giving small businesses the opportunity to execute their resiliency. Our small business community has continued to adapt through some of its most challenging economic conditions in recent history, but our policies have not kept pace. We need a regulatory framework that reflects the progress of the small business community. Commercial vacancies aren't just an economic issue. They're a signal that our current system is... working for small businesses. AB 1679 creates a real-world solution by allowing temporary activation of these spaces, helping bring back life to our streets, and supporting the kind of walkable transit-oriented communities California should be leading the charge on. Thank you. On behalf of the Independent Hospitality Coalition, I ask for your aye vote.

Good afternoon, members. My name is Malik Namoh, and I'm the owner of Twin Snakes Coffee right here in Sacramento. Five years ago, Twin Stinks Coffee was just an idea. I had a vision of creating a specialty coffee company that would bring people together, but like so many aspiring entrepreneurs, I didn't have the resources to immediately open a brick-and-mortar cafe. I instead started small. Between September and December of 2025, we operated approximately seven pop-up coffee events

No questions.

Thank you, Madam Chair, and thank you, Malik, for sharing your story. Pop-up's good. Fee's bad. I respectfully ask for I vote.

Thank you, Madam Chair.

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

Kevin Guzman with the California Medical Association in support.

Thank you, Madam Chair and members. Kevin Guzman of the California Medical Association, and we are pleased to support AB 2499. Physician practices and other providers are increasingly expected to operate in an electronic environment, but too often the process still breaks down with medical records or supporting documentation are needed to process the claim. Even when a claim is submitted electronically, providers may still have to pull records from the EHR, convert or scan them into separate files, upload them through a payer-specific portal, and then revert to fax or mail of the plan system cannot accept the full documentation package. That is inefficient for everyone. It creates duplicative work for physicians and their staff, increases administrative costs, delays payment, and makes it harder for providers to spend time where it matters most, caring for patients. AB 2499 is a practical step toward a more efficient claims process. It does not change what documentation a plan may request, and it does not require a plan to pay claims without appropriate review. It simply assures that when documentation is required to process a claim, plans maintain a workable electronic pathway to receive it. For physicians and medical practices that are already investing in electronic systems, this bill helps make sure the rest of the claims process keeps space. For these reasons, CMA respectfully asks for your aye vote. Thank you.